Provider Demographics
NPI:1578670782
Name:OLIVER FERNANDEZ PROFL DENTAL CORP
Entity Type:Organization
Organization Name:OLIVER FERNANDEZ PROFL DENTAL CORP
Other - Org Name:OLIVER FERNANDEZ DMD ST FRANCIS GENERAL DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:415-777-3337
Mailing Address - Street 1:683 FOLSOM STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107
Mailing Address - Country:US
Mailing Address - Phone:415-777-3337
Mailing Address - Fax:415-777-3338
Practice Address - Street 1:683 FOLSOM STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107
Practice Address - Country:US
Practice Address - Phone:415-777-3337
Practice Address - Fax:415-777-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty