Healthcare Provider Details

I. General information

NPI: 1780446104
Provider Name (Legal Business Name): HENRY QUAYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 FITZGERALD DR STE 106
PINOLE CA
94564-2257
US

IV. Provider business mailing address

1477 FITZGERALD DR STE 106
PINOLE CA
94564-2257
US

V. Phone/Fax

Practice location:
  • Phone: 424-239-9752
  • Fax:
Mailing address:
  • Phone: 424-239-9752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: