MEDICARE: DR. DAVID J POOLE D.D.S.

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	122300000X	Dentist	31092	CA

General Provider Information

NPI Number	:	1154793032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID J POOLE D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 2852
Second Line	:	41628 BIG BEAR BLVD.
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-2852
Country	:	US
Telephone Number	:	909-866-2646
Fax Number	:	909-866-1796

Provider Business Practice Location Address
First Line	:	41628 BIG BEAR BLVD.
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-2852
Country	:	US
Telephone Number	:	909-866-2646
Fax Number	:	909-866-1796

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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