Healthcare Provider Details

I. General information

NPI: 1902196231
Provider Name (Legal Business Name): UCSF AEGD PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PARNASSUS AVE D4000
SAN FRANCISCO CA
94143-2210
US

IV. Provider business mailing address

707 PARNASSUS AVE D4000
SAN FRANCISCO CA
94143-2210
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-3028
  • Fax: 415-476-0858
Mailing address:
  • Phone: 415-476-3028
  • Fax: 415-476-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberSP243
License Number StateCA

VIII. Authorized Official

Name: JOHN FEATHERSTONE
Title or Position: DEAN
Credential: PH.D.
Phone: 415-476-1323