Provider Demographics
NPI:1881852705
Name:GERONIMO, OSCAR
Entity Type:Individual
Prefix:
First Name:OSCAR
Middle Name:
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 JUDAH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3925 JUDAH STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122
Practice Address - Country:US
Practice Address - Phone:415-681-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice