Provider Demographics
NPI:1902004641
Name:DAVID SECCOMBE DENTAL CORPORATION
Entity Type:Organization
Organization Name:DAVID SECCOMBE DENTAL CORPORATION
Other - Org Name:DAVID SECCOMBE, DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SECCOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-626-5662
Mailing Address - Street 1:101 N INDIAN HILL BLVD STE C1-205
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4613
Mailing Address - Country:US
Mailing Address - Phone:909-626-5662
Mailing Address - Fax:909-626-5892
Practice Address - Street 1:101 N INDIAN HILL BLVD STE C1-205
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4613
Practice Address - Country:US
Practice Address - Phone:909-626-5662
Practice Address - Fax:909-626-5892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28236261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental