Provider Demographics
NPI:1497829162
Name:UCSF PERIODONTAL SPECIALTY CLINIC
Entity Type:Organization
Organization Name:UCSF PERIODONTAL SPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEATHERSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-476-1323
Mailing Address - Street 1:707 PARNASSUS AVE
Mailing Address - Street 2:ROOM D-3013
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0762
Mailing Address - Country:US
Mailing Address - Phone:415-476-1634
Mailing Address - Fax:415-476-1563
Practice Address - Street 1:707 PARNASSUS AVE
Practice Address - Street 2:ROOM D-3013
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0762
Practice Address - Country:US
Practice Address - Phone:415-476-1634
Practice Address - Fax:415-476-1563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2087OtherDELTA DENTAL