=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578670782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVER FERNANDEZ PROFL DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 683 FOLSOM STREET
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-777-3337
-----------------------------------------------------
Fax | 415-777-3338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 683 FOLSOM STREET
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-777-3337
-----------------------------------------------------
Fax | 415-777-3338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF CORPORATION
-----------------------------------------------------
Name | DR. OLIVER M FERNANDEZ
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 415-777-3337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 45688
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------