MEDICARE: DAVID P DEROSIER DDS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	35869	CA
2	122300000X	Dentist	35869	CA

General Provider Information

NPI Number	:	1013978477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID P DEROSIER DDS INC

Provider Business Mailing Address
First Line	:	3019 EMERSON STREET
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2603
Country	:	US
Telephone Number	:	619-222-7400
Fax Number	:	619-222-7018

Provider Business Practice Location Address
First Line	:	3019 EMERSON STREET
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2603
Country	:	US
Telephone Number	:	619-222-7400
Fax Number	:	619-222-7018

Authorized Official
Title or Position	:	DR OWNER
Name	:	DAVID PAUL DEROSIER
Credential	:	DDS
Telephone Number	:	619-222-7400

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	05/05/2008

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