Provider Demographics
NPI:1407430630
Name:SCDP EASTLAKE, LLC
Entity Type:Organization
Organization Name:SCDP EASTLAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKWEATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-922-0897
Mailing Address - Street 1:23911 DANZIG BAY
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4407
Mailing Address - Country:US
Mailing Address - Phone:650-922-0897
Mailing Address - Fax:
Practice Address - Street 1:890 EASTLAKE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4521
Practice Address - Country:US
Practice Address - Phone:619-421-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SILVER CREEK DENTAL PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty