Provider Demographics
NPI:1811259856
Name:SAN DIEGO DENTAL SLEEP THERAPY, LLC
Entity type:Organization
Organization Name:SAN DIEGO DENTAL SLEEP THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-460-0714
Mailing Address - Street 1:8530 LA MESA BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0966
Mailing Address - Country:US
Mailing Address - Phone:619-460-0714
Mailing Address - Fax:619-460-0707
Practice Address - Street 1:8530 LA MESA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0966
Practice Address - Country:US
Practice Address - Phone:619-460-0714
Practice Address - Fax:619-460-0707
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD B. EVANS, D.D.S., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31914332BC3200X, 335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31914OtherDENTIST - STATE LICENSE