Provider Demographics
NPI:1396139127
Name:BURGETT DENTAL CORPORATION
Entity type:Organization
Organization Name:BURGETT DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-361-3322
Mailing Address - Street 1:4541 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4010
Mailing Address - Country:US
Mailing Address - Phone:619-582-6000
Mailing Address - Fax:619-582-6002
Practice Address - Street 1:4541 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4010
Practice Address - Country:US
Practice Address - Phone:619-582-6000
Practice Address - Fax:619-582-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty