Healthcare Provider Details

I. General information

NPI: 1023216751
Provider Name (Legal Business Name): SAN DIEGO SPECIALTY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5638 MISSION CENTER RD #105
SAN DIEGO CA
92108-4348
US

IV. Provider business mailing address

5638 MISSION CENTER RD #105
SAN DIEGO CA
92108-4348
US

V. Phone/Fax

Practice location:
  • Phone: 619-293-3352
  • Fax: 619-293-0708
Mailing address:
  • Phone: 619-293-3352
  • Fax: 619-293-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number23856
License Number StateCA

VIII. Authorized Official

Name: STEPHEN NEEDLE
Title or Position: MANAGING DOCTOR
Credential: DDS
Phone: 619-293-3352