=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861704124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE WU FOGARTY DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2010
-----------------------------------------------------
Last Update Date | 03/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 MOUNTAIN BLVD STE 206
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-482-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2220 MOUNTAIN BLVD STE 206
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-482-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DR60171717
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 61271
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------