Provider Demographics
NPI:1053859710
Name:EDWARD SALL DENTAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD SALL DENTAL CORPORATION
Other - Org Name:TODD MORGAN DENTAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:SALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-987-7888
Mailing Address - Street 1:5471 KEARNY VILLA RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1143
Mailing Address - Country:US
Mailing Address - Phone:858-987-7888
Mailing Address - Fax:619-299-6222
Practice Address - Street 1:5471 KEARNY VILLA RD STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1143
Practice Address - Country:US
Practice Address - Phone:858-987-7888
Practice Address - Fax:619-299-6222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
CA33703332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC3761211OtherCALIFORNIA SECRETARY OF STATE
CA104553OtherDENTAL BOARD OF CALIFORNIA