Provider Demographics
NPI: | 1144739715 |
---|---|
Name: | PACIFIC PEDIATRIC DENTISTRY |
Entity Type: | Organization |
Organization Name: | PACIFIC PEDIATRIC DENTISTRY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | EUN HA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | YOU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 805-544-3434 |
Mailing Address - Street 1: | 1231 OSOS ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN LUIS OBISPO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93401-3619 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 805-544-3434 |
Mailing Address - Fax: | 805-544-3443 |
Practice Address - Street 1: | 1231 OSOS ST |
Practice Address - Street 2: | |
Practice Address - City: | SAN LUIS OBISPO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 93401-3619 |
Practice Address - Country: | US |
Practice Address - Phone: | 805-544-3434 |
Practice Address - Fax: | 805-544-3443 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-09-26 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 54656 | 1223P0221X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Single Specialty |