Provider Demographics
NPI:1922201219
Name:GRAND PLAZA DENTAL GROUP
Entity Type:Organization
Organization Name:GRAND PLAZA DENTAL GROUP
Other - Org Name:PATTON DENTAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-560-1461
Mailing Address - Street 1:3253 MOUNT TAMI DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4634
Mailing Address - Country:US
Mailing Address - Phone:858-560-1461
Mailing Address - Fax:858-560-2001
Practice Address - Street 1:137 S LAS POSAS RD STE 250
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2470
Practice Address - Country:US
Practice Address - Phone:760-752-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8996301Medicaid