Healthcare Provider Details

I. General information

NPI: 1093777278
Provider Name (Legal Business Name): PACIFIC ORAL PATHOLOGY LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 5TH ST
SAN FRANCISCO CA
94103-2919
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 415-929-6572
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LEWIS EVERSOLE
Title or Position: PRESIDENT
Credential: DDS
Phone: 415-929-6572