Provider Demographics
NPI:1093947814
Name:BARSTOW FAMILY DENTAL
Entity Type:Organization
Organization Name:BARSTOW FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:OLAFSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-256-1083
Mailing Address - Street 1:1940 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3218
Mailing Address - Country:US
Mailing Address - Phone:760-256-1083
Mailing Address - Fax:760-256-0079
Practice Address - Street 1:1940 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3218
Practice Address - Country:US
Practice Address - Phone:760-256-1083
Practice Address - Fax:760-256-0079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BARSTOW FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty