NPIMap

Organization Active NPI

Pediatric Dentistry of San Clemente

  • Dental Clinic/Center
  • San Clemente, CA
National Provider Identifier
1902687346
Registry record updated Oct 11, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
Legal business name
PEDIATRIC DENTISTRY OF SAN CLEMENTE
Practice address
903 Calle Amanecer Ste 110
San Clemente, CA 92673-6253
Phone
(949) 361-2838
NPI assigned
Oct 11, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 11, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jacob K Lee, DDSNPI 1083768725
Title
Ceo
Phone
(949) 361-2838

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X Primary

Addresses

Primary practice location

903 Calle Amanecer Ste 110
San Clemente, CA 92673-6253

Mailing address

903 Calle Amanecer Ste 110
San Clemente, CA 92673-6253
Phone (949) 361-2838

Other identifiers 3

IdentifierTypeStateIssuer
1790281202OtherCANPPES
1083768725OtherCANPPES
1437689395OtherCANPPES

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1696982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696982400000",
    "number": "1902687346",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "903 CALLE AMANECER STE 110",
            "city": "SAN CLEMENTE",
            "state": "CA",
            "postal_code": "926736253",
            "telephone_number": "949-361-2838"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "903 CALLE AMANECER STE 110",
            "city": "SAN CLEMENTE",
            "state": "CA",
            "postal_code": "926736253",
            "telephone_number": "949-361-2838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC DENTISTRY OF SAN CLEMENTE",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-10-11",
        "last_updated": "2023-10-11",
        "certification_date": "2023-10-11",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "JACOB",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "949-361-2838",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPPES",
            "identifier": "1790281202",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPPES",
            "identifier": "1083768725",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPPES",
            "identifier": "1437689395",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in San Clemente, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.