Healthcare Provider Details

I. General information

NPI: 1699796276
Provider Name (Legal Business Name): TORREY PINES ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE 304
SAN DIEGO CA
92130-3085
US

IV. Provider business mailing address

12395 EL CAMINO REAL SUITE 304
SAN DIEGO CA
92130-3085
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-3393
  • Fax: 858-793-3383
Mailing address:
  • Phone: 858-793-3393
  • Fax: 858-793-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER STEPHEN KINGSTON
Title or Position: SENIOR PARTNER
Credential: DDS
Phone: 858-793-3393