Healthcare Provider Details

I. General information

NPI: 1518726702
Provider Name (Legal Business Name): GILMORE ORTHODONTICS DENTAL PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9870 HIBERT ST STE D9
SAN DIEGO CA
92131-1091
US

IV. Provider business mailing address

9870 HIBERT ST STE D9
SAN DIEGO CA
92131-1091
US

V. Phone/Fax

Practice location:
  • Phone: 858-433-7377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KELLY GODDEYNE
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 858-433-7377