Provider Demographics
NPI:1497946933
Name:LAJOLLA COSMETIC & FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:LAJOLLA COSMETIC & FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-459-5591
Mailing Address - Street 1:470 NAUTILUS ST
Mailing Address - Street 2:# 212
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-459-5591
Mailing Address - Fax:858-459-4242
Practice Address - Street 1:470 NAUTILUS ST
Practice Address - Street 2:# 212
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-459-5591
Practice Address - Fax:858-459-4242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAJOLLA COSMETIC & FAMILY DENTISTRY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-08
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA440551223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty