Healthcare Provider Details

I. General information

NPI: 1376803254
Provider Name (Legal Business Name): SAN DIEGO CENTER FOR ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 FROST ST SUITE 311
SAN DIEGO CA
92123-4205
US

IV. Provider business mailing address

8008 FROST ST SUITE 311
SAN DIEGO CA
92123-4205
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-5175
  • Fax: 858-292-9946
Mailing address:
  • Phone: 858-292-5175
  • Fax: 858-292-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN JANE O'KEEFE
Title or Position: ADMINISTRATOR
Credential:
Phone: 858-292-5175