Provider Demographics
NPI:1639228950
Name:SAN BRUNO AVE DENTAL CLINIC CORP
Entity Type:Organization
Organization Name:SAN BRUNO AVE DENTAL CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-656-2868
Mailing Address - Street 1:2817 SAN BRUNO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-1510
Mailing Address - Country:US
Mailing Address - Phone:415-656-2868
Mailing Address - Fax:415-656-2865
Practice Address - Street 1:2817 SAN BRUNO AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-1510
Practice Address - Country:US
Practice Address - Phone:415-656-2868
Practice Address - Fax:415-656-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB377441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty