Healthcare Provider Details

I. General information

NPI: 1104005529
Provider Name (Legal Business Name): PENINSULA ORTHODONTIC GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BIRCH ST STE 100
REDWOOD CITY CA
94062-1480
US

IV. Provider business mailing address

563 LEAHY ST
REDWOOD CITY CA
94061-3877
US

V. Phone/Fax

Practice location:
  • Phone: 650-298-8400
  • Fax:
Mailing address:
  • Phone: 650-260-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number50540
License Number StateCA

VIII. Authorized Official

Name: JAMES TSAU
Title or Position: PRESIDENT
Credential: DMD
Phone: 650-260-2868