Provider Demographics
NPI:1114239738
Name:DAVID E. BROCKETT D.D.S. INC.
Entity Type:Organization
Organization Name:DAVID E. BROCKETT D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EASTMAN
Authorized Official - Last Name:BROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-454-1468
Mailing Address - Street 1:7804 IVANHOE AVE.
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-454-1468
Mailing Address - Fax:858-454-1696
Practice Address - Street 1:7804 IVANHOE AVE.
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-454-1468
Practice Address - Fax:858-454-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty