Healthcare Provider Details

I. General information

NPI: 1568475036
Provider Name (Legal Business Name): JOHN FREDERICK CONRAD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 DURANT AVE
BERKELEY CA
94704-1607
US

IV. Provider business mailing address

2817 PIEDMONT AVE
BERKELEY CA
94705-2313
US

V. Phone/Fax

Practice location:
  • Phone: 510-848-8606
  • Fax: 510-848-0844
Mailing address:
  • Phone: 510-848-8606
  • Fax: 510-848-0844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD21441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: