Provider Demographics
NPI:1417685041
Name:AFAMILYFRIEND TELEDENTISTRY
Entity Type:Organization
Organization Name:AFAMILYFRIEND TELEDENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-436-3335
Mailing Address - Street 1:1502 N WILLOWSPRING DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5634
Mailing Address - Country:US
Mailing Address - Phone:760-436-3335
Mailing Address - Fax:
Practice Address - Street 1:855 MARINA BAY PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-6497
Practice Address - Country:US
Practice Address - Phone:707-727-8326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE2797118OtherDRIVING LICENSE
CAC1120725OtherDL