=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720759244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSION BAY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2021
-----------------------------------------------------
Last Update Date | 09/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 4TH ST STE C
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94158-2425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-523-4939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 4TH ST STE C
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94158-2425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | JANE CHOI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 919-633-8069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------