Healthcare Provider Details

I. General information

NPI: 1508294927
Provider Name (Legal Business Name): UNIVERSITY OF THE PACIFIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 5TH ST OFMSC SUITE 3F
SAN FRANCISCO CA
94103-2919
US

IV. Provider business mailing address

155 5TH ST STE 3F
SAN FRANCISCO CA
94103-2919
US

V. Phone/Fax

Practice location:
  • Phone: 415-929-6617
  • Fax: 415-794-3305
Mailing address:
  • Phone: 415-929-6617
  • Fax: 415-794-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ED PEGUEROS
Title or Position: ASSOC DEAN, BUDGET & FIN ADMIN, AO
Credential:
Phone: 415-351-7192