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General NPI Number Information
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NPI Number | 1144680661
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Entity Type | Organization
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Legal Business Name | SUN SMILE DENTAL GROUP
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Dates
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Enumeration Date | 02/25/2016
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Last Update Date | 02/25/2016
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Provider Practice Location Address
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Address Line | 1582 W SAN MARCOS BLVD SUITE 201
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City | SAN MARCOS
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State | CA
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Zip | 92078-4081
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Country | US
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Telephone | 760-744-1300
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Fax | 760-744-1342
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Provider Business Mailing Address
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Address Line | 1582 W SAN MARCOS BLVD SUITE 201
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City | SAN MARCOS
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State | CA
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Zip | 92078-4081
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Country | US
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Telephone | 760-744-1300
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Fax | 760-744-1342
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHISHIR NAVINCHANDRA SHAH
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Credential | DDS
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Telephone | 760-744-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5402
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License Number State | CA
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