Provider Demographics
NPI:1376803254
Name:SAN DIEGO CENTER FOR ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:SAN DIEGO CENTER FOR ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:O'KEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-292-5175
Mailing Address - Street 1:8008 FROST ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4205
Mailing Address - Country:US
Mailing Address - Phone:858-292-5175
Mailing Address - Fax:858-292-9946
Practice Address - Street 1:8008 FROST ST
Practice Address - Street 2:SUITE 311
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4205
Practice Address - Country:US
Practice Address - Phone:858-292-5175
Practice Address - Fax:858-292-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty