=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780984252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN CALIFORNIA FACIAL AND ORAL SURGERY CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 10/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 ESTUDILLO AVE SUITE 100
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-483-5111
-----------------------------------------------------
Fax | 510-483-9793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 ESTUDILLO AVE SUITE 100
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-483-5111
-----------------------------------------------------
Fax | 510-483-9793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | DR. JEFFREY CLAYTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 510-483-5111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 39775
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 39567
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------