Healthcare Provider Details

I. General information

NPI: 1801025408
Provider Name (Legal Business Name): CHILDREN'S DENTAL ANESTHESIA GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST DEPT. ANESTHESIOLOGY
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

747 52ND ST DEPT. ANESTHESIOLOGY
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 510-295-7913
  • Fax:
Mailing address:
  • Phone: 510-295-7913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberFNP38903
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL KENNETH AUSTIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-295-7913