Provider Demographics
NPI:1376738062
Name:COURTNEY L. STAADECKER, DDS, MS AND SCOTT T. OZAKI, DDS, INC.
Entity Type:Organization
Organization Name:COURTNEY L. STAADECKER, DDS, MS AND SCOTT T. OZAKI, DDS, INC.
Other - Org Name:EASTLAKE PERIODONTICS AND IMPLANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:TADASHI
Authorized Official - Last Name:OZAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-482-3205
Mailing Address - Street 1:2452 FENTON ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3516
Mailing Address - Country:US
Mailing Address - Phone:619-482-3205
Mailing Address - Fax:619-482-3206
Practice Address - Street 1:2452 FENTON ST
Practice Address - Street 2:SUITE 302
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3516
Practice Address - Country:US
Practice Address - Phone:619-482-3205
Practice Address - Fax:619-482-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41977261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental