Provider Demographics
NPI:1780728436
Name:BOULEVARD DENTAL CENTER
Entity type:Organization
Organization Name:BOULEVARD DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-584-8975
Mailing Address - Street 1:3531 EL CAJON BLVD #A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104
Mailing Address - Country:US
Mailing Address - Phone:619-584-8975
Mailing Address - Fax:619-584-0682
Practice Address - Street 1:3531 EL CAJON BLVD #A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104
Practice Address - Country:US
Practice Address - Phone:619-584-8975
Practice Address - Fax:619-584-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental