Provider Demographics
NPI:1164607792
Name:POOLER DENTAL CORPORATION
Entity Type:Organization
Organization Name:POOLER DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:POOLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-756-6968
Mailing Address - Street 1:66 SAN PEDRO RD STE B
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-2577
Mailing Address - Country:US
Mailing Address - Phone:650-756-6968
Mailing Address - Fax:650-756-9271
Practice Address - Street 1:66 SAN PEDRO RD STE B
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-2577
Practice Address - Country:US
Practice Address - Phone:650-756-6968
Practice Address - Fax:650-756-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35647261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental