Healthcare Provider Details

I. General information

NPI: 1861452641
Provider Name (Legal Business Name): L R EVERSOLE A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9292 CHESAPEAKE DR STE 100
SAN DIEGO CA
92123-1059
US

IV. Provider business mailing address

PO BOX 643
POWAY CA
92074-0643
US

V. Phone/Fax

Practice location:
  • Phone: 858-492-9500
  • Fax:
Mailing address:
  • Phone: 858-513-3889
  • Fax: 858-513-3893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEWIS R EVERSOLE
Title or Position: PRESIDENT
Credential: DDS
Phone: 858-492-9500