=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477694412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARY JAY SCHILLER D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 W PORTAL AVE SUITE 300
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94127-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-664-4532
-----------------------------------------------------
Fax | 415-664-5279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1261 WALLER ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94117-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-861-5545
-----------------------------------------------------
Fax | 415-552-2036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 20461
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------