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General NPI Number Information
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NPI Number | 1508912858
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Entity Type | Organization
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Legal Business Name | EAST LAKE FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 970 EASTLAKE PKWY SUITE 103
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City | CHULA VISTA
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State | CA
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Zip | 91914-3561
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Country | US
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Telephone | 619-482-2920
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Fax | 619-482-2924
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Provider Business Mailing Address
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Address Line | 970 EASTLAKE PKWY SUITE 103
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City | CHULA VISTA
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State | CA
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Zip | 91914-3561
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Country | US
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Telephone | 619-482-2920
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Fax | 619-482-2924
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Authorized Official
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Title or Position | DDS
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Name | DR. ROBERT E MAROON
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Credential | D.D.S.,F.I.C.O.I
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Telephone | 619-482-2920
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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 | 43466
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License Number State | CA
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