Provider Demographics
NPI:1265554166
Name:MACVANE-PEARSON, MONICA GRISEL (DDS)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:GRISEL
Last Name:MACVANE-PEARSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4225
Practice Address - Street 1:3050 E 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2319
Practice Address - Country:US
Practice Address - Phone:510-535-4700
Practice Address - Fax:510-535-4283
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDSS4891122300000X
CA548911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist