Provider Demographics
NPI:1265493373
Name:FLINT, DERRICK (MD, DDS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:FLINT
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 PARNASSUS AVE RM C-522
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2206
Mailing Address - Country:US
Mailing Address - Phone:415-476-8221
Mailing Address - Fax:
Practice Address - Street 1:521 PARNASSUS AVE RM C-522
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2206
Practice Address - Country:US
Practice Address - Phone:415-794-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236795173000000X
TX276741223S0112X
CA594211223S0112X
CAA112886204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY145SH1Medicare ID - Type Unspecified
NYI43636Medicare UPIN