Provider Demographics
NPI:1972830180
Name:DEL MAR PEDIATRIC & ADOLESCENTS DENTAL GROUP
Entity type:Organization
Organization Name:DEL MAR PEDIATRIC & ADOLESCENTS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SOUDABEH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARAFI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:858-259-1400
Mailing Address - Street 1:12750 CARMEL COUNTRY RD STE 215
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2172
Mailing Address - Country:US
Mailing Address - Phone:858-259-1400
Mailing Address - Fax:858-259-1401
Practice Address - Street 1:12750 CARMEL COUNTRY RD STE 215
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2172
Practice Address - Country:US
Practice Address - Phone:858-259-1400
Practice Address - Fax:858-259-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52929261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental