Basic Information
| Provider Information | |||||||||
| NPI: | 1992348866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLEMAN DENTAL ASSOCIATES CA, A DENTAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAMPUS SMILES DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7575 SAN FELIPE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770631776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132276453 | ||||||||
| FaxNumber: | 8558277442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2952 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921023241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197984613 | ||||||||
| FaxNumber: | 6197984613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2019 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | HARVEY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7137812800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.