Provider Demographics
NPI:1508053323
Name:GEORGE R BRAITHWAITE
Entity Type:Organization
Organization Name:GEORGE R BRAITHWAITE
Other - Org Name:FAMILY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRAITHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:760-724-6537
Mailing Address - Street 1:630 ALTA VISTA DR
Mailing Address - Street 2:#108
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5504
Mailing Address - Country:US
Mailing Address - Phone:760-724-6537
Mailing Address - Fax:760-724-5115
Practice Address - Street 1:630 ALTA VISTA DR
Practice Address - Street 2:#108
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5504
Practice Address - Country:US
Practice Address - Phone:760-724-6537
Practice Address - Fax:760-724-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA249371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty