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General NPI Number Information
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NPI Number | 1396111530
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Entity Type | Organization
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Legal Business Name | GARY AND MARY WEST SENIOR DENTAL CENTER, INC.
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Dates
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Enumeration Date | 08/11/2015
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Last Update Date | 08/11/2015
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Provider Practice Location Address
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Address Line | 1525 4TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92101-3107
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Country | US
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Telephone | 760-602-5862
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Fax |
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Provider Business Mailing Address
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Address Line | 1525 4TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92101-3107
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Country | US
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Telephone | 760-602-5862
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Fax |
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Authorized Official
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Title or Position | PRESIDENT AND DENTIST
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Name | DR. KAREN BECERRA
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Credential | DDS, MPH
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Telephone | 760-602-5862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 55692
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License Number State | CA
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