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General NPI Number Information
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NPI Number | 1114239738
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Entity Type | Organization
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Legal Business Name | DAVID E. BROCKETT D.D.S. INC.
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Dates
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Enumeration Date | 07/12/2010
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Last Update Date | 07/12/2010
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Provider Practice Location Address
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Address Line | 7804 IVANHOE AVE.
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City | LA JOLLA
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State | CA
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Zip | 92037
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Country | US
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Telephone | 858-454-1468
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Fax | 858-454-1696
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Provider Business Mailing Address
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Address Line | 7804 IVANHOE AVE.
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City | LA JOLLA
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State | CA
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Zip | 92037
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Country | US
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Telephone | 858-454-1468
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Fax | 858-454-1696
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID EASTMAN BROCKETT
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Credential | DDS.
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Telephone | 858-454-1468
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 25483
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License Number State | CA
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