Provider Demographics
NPI:1861452641
Name:L R EVERSOLE A DENTAL CORPORATION
Entity Type:Organization
Organization Name:L R EVERSOLE A DENTAL CORPORATION
Other - Org Name:ORAL PATHOLOGY DIAGNOSTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVERSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-492-9500
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92074-0643
Mailing Address - Country:US
Mailing Address - Phone:858-513-3889
Mailing Address - Fax:858-513-3893
Practice Address - Street 1:9292 CHESAPEAKE DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1059
Practice Address - Country:US
Practice Address - Phone:858-492-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18514Medicare PIN