Provider Demographics
NPI:1508912858
Name:EAST LAKE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:EAST LAKE FAMILY DENTISTRY
Other - Org Name:ROBERT EMAROON
Other - Org Type:Other Name
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MAROON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,FICOI
Authorized Official - Phone:619-482-2920
Mailing Address - Street 1:970 EASTLAKE PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3561
Mailing Address - Country:US
Mailing Address - Phone:619-482-2920
Mailing Address - Fax:619-482-2924
Practice Address - Street 1:970 EASTLAKE PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3561
Practice Address - Country:US
Practice Address - Phone:619-482-2920
Practice Address - Fax:619-482-2924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty