Provider Demographics
NPI:1447455381
Name:CHILDREN'S DENTAL HEALTH ASSOCIATION OF SAN DIEGO
Entity type:Organization
Organization Name:CHILDREN'S DENTAL HEALTH ASSOCIATION OF SAN DIEGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF GENERAL DENTISTRY
Authorized Official - Prefix:
Authorized Official - First Name:MARILUCI
Authorized Official - Middle Name:C
Authorized Official - Last Name:BYRNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-234-8131
Mailing Address - Street 1:1270 24TH STREET
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 1:4100 NORMAL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2653
Practice Address - Country:US
Practice Address - Phone:619-234-8131
Practice Address - Fax:619-234-0048
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTAL HEALTH ASSOCIATION OF SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-20
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9008602Medicare ID - Type Unspecified