Provider Demographics
NPI:1093777278
Name:PACIFIC ORAL PATHOLOGY LABORATORY
Entity Type:Organization
Organization Name:PACIFIC ORAL PATHOLOGY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-929-6572
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-8950
Practice Address - Street 1:155 5TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2919
Practice Address - Country:US
Practice Address - Phone:415-929-6572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB64366FMedicaid
CALAB64366FMedicaid