Healthcare Provider Details

I. General information

NPI: 1568502821
Provider Name (Legal Business Name): FREDRIC R WARREN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W PORTAL AVE
SAN FRANCISCO CA
94127-1303
US

IV. Provider business mailing address

15 W PORTAL AVE
SAN FRANCISCO CA
94127-1303
US

V. Phone/Fax

Practice location:
  • Phone: 415-681-2418
  • Fax:
Mailing address:
  • Phone: 415-681-2418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD29865
License Number StateCA

VIII. Authorized Official

Name: DR. FREDRIC R WARREN
Title or Position: PRESIDENT, ORTHODONTIST
Credential: D.D.S., M.S.D.
Phone: 415-681-2418