Provider Demographics
NPI:1922157213
Name:VARBONCOEUR, ANTHONY PAUL
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:VARBONCOEUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-463-4486
Mailing Address - Fax:
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:SUITE 129
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-463-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA375121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery