Provider Demographics
NPI:1861410847
Name:COPP, MICHAEL BRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:COPP
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 1:120 C AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1990
Mailing Address - Country:US
Mailing Address - Phone:619-435-3185
Mailing Address - Fax:619-435-6560
Practice Address - Street 1:120 C AVE STE 150
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1990
Practice Address - Country:US
Practice Address - Phone:619-435-3185
Practice Address - Fax:619-435-6560
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA373251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice