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General NPI Number Information
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NPI Number | 1164607792
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Entity Type | Organization
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Legal Business Name | POOLER DENTAL CORPORATION
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Dates
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Enumeration Date | 01/02/2008
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Last Update Date | 01/02/2008
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Provider Practice Location Address
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Address Line | 66 SAN PEDRO RD STE B
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City | DALY CITY
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State | CA
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Zip | 94014-2577
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Country | US
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Telephone | 650-756-6968
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Fax | 650-756-9271
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Provider Business Mailing Address
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Address Line | 66 SAN PEDRO RD STE B
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City | DALY CITY
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State | CA
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Zip | 94014-2577
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Country | US
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Telephone | 650-756-6968
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Fax | 650-756-9271
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Authorized Official
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Title or Position | DENTIST
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Name | DIANE MARIE POOLER
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Credential | DDS
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Telephone | 650-756-6968
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 35647
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License Number State | CA
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