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General NPI Number Information
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NPI Number | 1730535774
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Entity Type | Organization
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Legal Business Name | 1012 GROUP, INC
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Dates
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Enumeration Date | 05/09/2016
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Last Update Date | 05/09/2016
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Provider Practice Location Address
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Address Line | 800 S B ST SUITE #200
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City | SAN MATEO
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State | CA
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Zip | 94401-4271
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Country | US
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Telephone | 650-458-3727
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Fax |
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Provider Business Mailing Address
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Address Line | 800 S B ST SUITE #200
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City | SAN MATEO
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State | CA
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Zip | 94401-4271
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Country | US
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Telephone | 650-458-3727
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | PATTI BOLANDER
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Credential |
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Telephone | 650-458-3727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 58767
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License Number State | CA
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