Provider Demographics
NPI:1407353873
Name:ODENWALDER DENTAL INC
Entity Type:Organization
Organization Name:ODENWALDER DENTAL INC
Other - Org Name:MISSION FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:ODENWALDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:760-439-5515
Mailing Address - Street 1:3935 MISSION AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7802
Mailing Address - Country:US
Mailing Address - Phone:760-439-5515
Mailing Address - Fax:
Practice Address - Street 1:3935 MISSION AVE STE 9
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7802
Practice Address - Country:US
Practice Address - Phone:760-439-5515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty