Provider Demographics
NPI:1154793032
Name:POOLE, DAVID J (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:POOLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:JOSEPH
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 2852
Mailing Address - Street 2:41628 BIG BEAR BLVD.
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-2852
Mailing Address - Country:US
Mailing Address - Phone:909-866-2646
Mailing Address - Fax:909-866-1796
Practice Address - Street 1:41628 BIG BEAR BLVD.
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-2852
Practice Address - Country:US
Practice Address - Phone:909-866-2646
Practice Address - Fax:909-866-1796
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist