Provider Demographics
NPI:1902196231
Name:UCSF AEGD PROGRAM
Entity Type:Organization
Organization Name:UCSF AEGD PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEATHERSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-476-1323
Mailing Address - Street 1:707 PARNASSUS AVE
Mailing Address - Street 2:D4000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2210
Mailing Address - Country:US
Mailing Address - Phone:415-476-3028
Mailing Address - Fax:415-476-0858
Practice Address - Street 1:707 PARNASSUS AVE
Practice Address - Street 2:D4000
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2210
Practice Address - Country:US
Practice Address - Phone:415-476-3028
Practice Address - Fax:415-476-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP2431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty