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1001 Potrero Avenue, Bldg 5, Room 1n1 San Francisco CA 94110-3518 | |
| (415) 502-0661 | |
| (415) 476-6206 |
| Full Name | |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 1001 Potrero Avenue, Bldg 5, Room 1n1, San Francisco, California |
| Authorized Official Name and Position | Terrel Ross (INTERIM DIRECTOR) |
| Authorized Official Contact | 4154763625 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 743749 Los Angeles CA 90074-3749 Ph: (415) 514-3000 | 1001 Potrero Avenue, Bldg 5, Room 1n1 San Francisco CA 94110-3518 Ph: (415) 502-0661 |
| NPI Number | 1811475759 |
|---|---|
| Provider Enumeration Date | 08/02/2018 |
| Last Update Date | 01/28/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811475759 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Primary |
| 204E00000X | Oral & Maxillofacial Surgery | (* (Not Available)) | Secondary |
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