Healthcare Provider Details

I. General information

NPI: 1508082819
Provider Name (Legal Business Name): PETER MICHAEL LOOMER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PARNASSUS AVENUE BOX 0762
SAN FRANCISCO CA
94903-0762
US

IV. Provider business mailing address

521 PARNASSUS AVE. C628 BOX 0650
SAN FRANCISCO CA
94903-5004
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1731
  • Fax:
Mailing address:
  • Phone: 415-502-7896
  • Fax: 415-502-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberSP198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: