Provider Demographics
NPI:1942869961
Name:UCSF SCHOOL OF DENTISTRY CLINIC NO. 1
Entity Type:Organization
Organization Name:UCSF SCHOOL OF DENTISTRY CLINIC NO. 1
Other - Org Name:UCSF PREDOCTORAL UNIVERSITY PROJECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN, SCHOOL OF DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, DMSC
Authorized Official - Phone:415-476-1323
Mailing Address - Street 1:707 PARNASSUS AVENUE D1130
Mailing Address - Street 2:BOX 0752
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2210
Mailing Address - Country:US
Mailing Address - Phone:415-476-5747
Mailing Address - Fax:415-476-6110
Practice Address - Street 1:707 PARNASSUS AVE # D-2000
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2210
Practice Address - Country:US
Practice Address - Phone:415-476-5747
Practice Address - Fax:415-476-6110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-12
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU01002-01OtherDENTI-CAL UNIVERSITY PROJECT
CA1528151529OtherDENTI-CAL