=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861585804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACKARD DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 GRAND AVE
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-729-4904
-----------------------------------------------------
Fax | 760-729-3132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 GRAND AVE
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-729-4904
-----------------------------------------------------
Fax | 760-729-3132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK D PACKARD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 760-729-4904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------