MEDICARE: DR. JOSEPH HENRY FALLON IV 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	1223G0001X	General Practice Dentistry	25515	CA

General Provider Information

NPI Number	:	1184748725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH HENRY FALLON IV D.D.S.

Provider Business Mailing Address
First Line	:	4633 INGRAHAM ST
Second Line	:	SUITE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-8713
Country	:	US
Telephone Number	:	858-272-3771
Fax Number	:	858-272-3799

Provider Business Practice Location Address
First Line	:	4633 INGRAHAM ST
Second Line	:	SUITE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-8713
Country	:	US
Telephone Number	:	858-272-3771
Fax Number	:	858-272-3799

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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