Provider Demographics
NPI:1245351915
Name:SCRYDLOFF, MICHAEL BORIS (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BORIS
Last Name:SCRYDLOFF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9932 MERCY RD # 104-105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-5033
Mailing Address - Country:US
Mailing Address - Phone:858-566-2151
Mailing Address - Fax:
Practice Address - Street 1:9932 MERCY RD # 104-105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-5033
Practice Address - Country:US
Practice Address - Phone:858-566-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA345561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice