Healthcare Provider Details

I. General information

NPI: 1174222889
Provider Name (Legal Business Name): OUTREACH DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST RM 1925
SAN FRANCISCO CA
94108-4107
US

IV. Provider business mailing address

2194 VIZCAYA CIR
CAMPBELL CA
95008-5646
US

V. Phone/Fax

Practice location:
  • Phone: 415-297-0378
  • Fax:
Mailing address:
  • Phone: 415-297-0378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALBINA BATCHAEVA
Title or Position: CEO
Credential: DDS
Phone: 415-297-0378