Provider Demographics
NPI:1144593682
Name:POOL & CREIGHTON DENTAL CORPORATION
Entity Type:Organization
Organization Name:POOL & CREIGHTON DENTAL CORPORATION
Other - Org Name:WASHINGTON SQUARE PARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-891-9773
Mailing Address - Street 1:1719 POWELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1719 POWELL ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-2808
Practice Address - Country:US
Practice Address - Phone:415-891-9773
Practice Address - Fax:415-398-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58832122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty