Healthcare Provider Details

I. General information

NPI: 1336101583
Provider Name (Legal Business Name): ORAL PATHOLOGY LABORATORY UCSF SCHOOL OF DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 PARNASSUS AVE
SAN FRANCISCO CA
94143-2205
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-4868
  • 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: RICHARD C.K. JORDAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 415-476-4868