Provider Demographics
NPI:1831567411
Name:POTRERO HILL DENTAL
Entity type:Organization
Organization Name:POTRERO HILL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-890-4449
Mailing Address - Street 1:698 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-2636
Mailing Address - Country:US
Mailing Address - Phone:415-890-4449
Mailing Address - Fax:
Practice Address - Street 1:698 VERMONT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-2636
Practice Address - Country:US
Practice Address - Phone:415-890-4449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-12
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61714122300000X
CA592941223E0200X
CA60629122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty