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General NPI Number Information
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NPI Number | 1861452641
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Entity Type | Organization
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Legal Business Name | L R EVERSOLE A DENTAL CORPORATION
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Dates
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Enumeration Date | 03/24/2006
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 9292 CHESAPEAKE DR STE 100
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City | SAN DIEGO
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State | CA
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Zip | 92123-1059
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Country | US
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Telephone | 858-492-9500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 643
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City | POWAY
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State | CA
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Zip | 92074-0643
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Country | US
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Telephone | 858-513-3889
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Fax | 858-513-3893
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Authorized Official
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Title or Position | PRESIDENT
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Name | LEWIS R EVERSOLE
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Credential | DDS
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Telephone | 858-492-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number |
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License Number State |
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