Healthcare Provider Details

I. General information

NPI: 1235649690
Provider Name (Legal Business Name): MAC DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9855 ERMA ROAD, #110 SCRIPPS PERIODONTICS
SAN DIEGO CA
92131
US

IV. Provider business mailing address

8534 HOPSEED LANE
SAN DIEGO CA
92129
US

V. Phone/Fax

Practice location:
  • Phone: 240-383-7623
  • Fax:
Mailing address:
  • Phone: 240-383-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number45585
License Number StateCA

VIII. Authorized Official

Name: DR. FRANK MAC
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 240-383-7623