Provider Demographics
NPI:1275629958
Name:CAILLOUEL, BRENDA K (BS, DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:K
Last Name:CAILLOUEL
Suffix:
Gender:F
Credentials:BS, DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2466 AZURE COAST DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3508
Mailing Address - Country:US
Mailing Address - Phone:858-222-2454
Mailing Address - Fax:
Practice Address - Street 1:3936 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1418
Practice Address - Country:US
Practice Address - Phone:858-202-0393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46565122300000X
FLDN-16530122300000X
HIDT-2186122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist