Provider Demographics
NPI:1710548375
Name:SAN DIEGO DENTAL ANESTHESIA
Entity Type:Organization
Organization Name:SAN DIEGO DENTAL ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-339-0760
Mailing Address - Street 1:8677 VILLA LA JOLLA DR # 1255
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2354
Mailing Address - Country:US
Mailing Address - Phone:619-339-0760
Mailing Address - Fax:
Practice Address - Street 1:1287 CARLSBAD VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:619-339-0760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty