=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851499412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSET PREMIER DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 NORIEGA ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94122-4241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-682-2415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 NORIEGA ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94122-4241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-682-2415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DENTIST
-----------------------------------------------------
Name | DR. JUSTIN TIN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 415-682-2415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | B37744
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------