Provider Demographics
NPI:1467921288
Name:DO, ETHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:DO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 9TH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2333
Mailing Address - Country:US
Mailing Address - Phone:909-538-3269
Mailing Address - Fax:
Practice Address - Street 1:3017 TELEGRAPH AVE STE 310
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2049
Practice Address - Country:US
Practice Address - Phone:510-841-7424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103035122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist