Provider Demographics
NPI:1649626490
Name:VALERI SACKNOFF D D S INC
Entity type:Organization
Organization Name:VALERI SACKNOFF D D S INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERI
Authorized Official - Middle Name:
Authorized Official - Last Name:SACKNOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-485-6900
Mailing Address - Street 1:15725 POMERADO RD
Mailing Address - Street 2:STE 110
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2068
Mailing Address - Country:US
Mailing Address - Phone:858-485-6900
Mailing Address - Fax:858-485-5875
Practice Address - Street 1:15725 POMERADO RD
Practice Address - Street 2:STE 110
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2068
Practice Address - Country:US
Practice Address - Phone:858-485-6900
Practice Address - Fax:858-485-5875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34896332BC3200X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7566670001Medicare NSC