Provider Demographics
NPI:1730268657
Name:UCSF SFGH MAXILLO FACIAL SURGERY CL. #20-4
Entity type:Organization
Organization Name:UCSF SFGH MAXILLO FACIAL SURGERY CL. #20-4
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEATHERSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-476-8997
Mailing Address - Street 1:1001 POTRERO AVE
Mailing Address - Street 2:ROOM 1N1
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3518
Mailing Address - Country:US
Mailing Address - Phone:415-206-6128
Mailing Address - Fax:415-502-0817
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:ROOM 1N1
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-6128
Practice Address - Fax:415-502-0817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0041991Medicaid