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General NPI Number Information
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NPI Number | 1407353873
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Entity Type | Organization
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Legal Business Name | ODENWALDER DENTAL INC
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Dates
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Enumeration Date | 04/11/2018
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Last Update Date | 04/11/2018
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Provider Practice Location Address
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Address Line | 3935 MISSION AVE STE 9
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City | OCEANSIDE
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State | CA
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Zip | 92058-7802
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Country | US
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Telephone | 760-439-5515
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Fax |
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Provider Business Mailing Address
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Address Line | 3935 MISSION AVE STE 9
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City | OCEANSIDE
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State | CA
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Zip | 92058-7802
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Country | US
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Telephone | 760-439-5515
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SEAN KYLE ODENWALDER
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Credential | DMD
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Telephone | 760-439-5515
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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 | DDS101299
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License Number State | CA
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