Provider Demographics
NPI:1407273279
Name:UNIVERSITY OF THE PACIFIC
Entity Type:Organization
Organization Name:UNIVERSITY OF THE PACIFIC
Other - Org Name:PACIFIC ORAL & MAXILLOFACIAL PATHOLOGY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST DEAN, BUDGET & FIN ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGUEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-351-7192
Mailing Address - Street 1:155 5TH ST
Mailing Address - Street 2:POPL SUITE 407E
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2919
Mailing Address - Country:US
Mailing Address - Phone:415-929-6560
Mailing Address - Fax:415-929-6654
Practice Address - Street 1:155 5TH ST
Practice Address - Street 2:POPL SUITE 407E
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2919
Practice Address - Country:US
Practice Address - Phone:415-929-6560
Practice Address - Fax:415-929-6654
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF THE PACIFIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-18
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes292200000XLaboratoriesDental Laboratory
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLF 00002594OtherSTATE ID NUMBER
CA05D0643664OtherCLIA NUMBER