Healthcare Provider Details

I. General information

NPI: 1225797731
Provider Name (Legal Business Name): JAMES SPENCER BISBAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2021
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12750 CARMEL COUNTRY RD STE 202
SAN DIEGO CA
92130-2171
US

IV. Provider business mailing address

12750 CARMEL COUNTRY RD STE 202
SAN DIEGO CA
92130-2171
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-5363
  • Fax:
Mailing address:
  • Phone: 858-755-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number102311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: