Provider Demographics
NPI:1639590003
Name:PENINSULA PEDIATRIC DENTAL PRACTICE
Entity Type:Organization
Organization Name:PENINSULA PEDIATRIC DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-375-8300
Mailing Address - Street 1:50 S SAN MATEO DR STE 160
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3859
Mailing Address - Country:US
Mailing Address - Phone:650-375-8300
Mailing Address - Fax:650-375-8130
Practice Address - Street 1:50 S SAN MATEO DR STE 160
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3859
Practice Address - Country:US
Practice Address - Phone:650-375-8300
Practice Address - Fax:650-375-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA226731223P0221X
CA613911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386792919OtherDENTICAL
CA1386792919OtherALL INSURANCE CARRIER