Provider Demographics
NPI:1467649350
Name:SOUTH BAY PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTH BAY PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:W
Authorized Official - Last Name:PACOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:619-216-1100
Mailing Address - Street 1:2446 FENTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3516
Mailing Address - Country:US
Mailing Address - Phone:619-216-1100
Mailing Address - Fax:619-216-1127
Practice Address - Street 1:2446 FENTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3516
Practice Address - Country:US
Practice Address - Phone:619-216-1100
Practice Address - Fax:619-216-1127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty