Provider Demographics
NPI:1255453882
Name:CHILDREN'S DENTAL HEALTH CENTER OF SAN DIEGO
Entity type:Organization
Organization Name:CHILDREN'S DENTAL HEALTH CENTER OF SAN DIEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DENTAL OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILUCI
Authorized Official - Middle Name:COSTA
Authorized Official - Last Name:BYRNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-234-8131
Mailing Address - Street 1:1270 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2012
Mailing Address - Country:US
Mailing Address - Phone:619-234-8131
Mailing Address - Fax:619-234-0048
Practice Address - Street 1:1270 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2012
Practice Address - Country:US
Practice Address - Phone:619-234-8131
Practice Address - Fax:619-234-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty