Provider Demographics
NPI:1093992554
Name:BRANCH DENTAL CLINIC HORNO
Entity type:Organization
Organization Name:BRANCH DENTAL CLINIC HORNO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NAVY MEDICINE UBO PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:PO BOX 555221
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5221
Mailing Address - Country:US
Mailing Address - Phone:760-725-3213
Mailing Address - Fax:760-725-8223
Practice Address - Street 1:14TH STREET
Practice Address - Street 2:BUILDING 13128
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-3213
Practice Address - Fax:760-725-8223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAVAL HOSPITAL CAMP PENDLETON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-28
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental