Healthcare Provider Details

I. General information

NPI: 1912461831
Provider Name (Legal Business Name): PARKSIDE ORAL SURGERY & IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 SANTA CLARA AVE
ALAMEDA CA
94501-4633
US

IV. Provider business mailing address

2525 SANTA CLARA AVE
ALAMEDA CA
94501-4633
US

V. Phone/Fax

Practice location:
  • Phone: 510-865-1114
  • Fax: 510-227-6212
Mailing address:
  • Phone: 510-865-1114
  • Fax: 510-227-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. WENDY LIAO
Title or Position: CEO
Credential: DDS
Phone: 510-865-1114