MEDICARE: HILLSIDE FAMILY DENTAL CENTER

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	19777	CA

General Provider Information

NPI Number	:	1356781553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HILLSIDE FAMILY DENTAL CENTER

Provider Business Mailing Address
First Line	:	4990 70TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-1803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4990 70TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-1803
Country	:	US
Telephone Number	:	619-466-7166
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALAN MICHELS
Credential	:
Telephone Number	:	619-466-7166

Provider Enumeration Date	:	07/02/2013
Last Update Date	:	07/02/2013

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