Healthcare Provider Details

I. General information

NPI: 1770575888
Provider Name (Legal Business Name): DEBRA S EDSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

IV. Provider business mailing address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-5000
  • Fax: 760-414-3710
Mailing address:
  • Phone: 760-631-5000
  • Fax: 760-414-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20568
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number56859
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019027560
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: