Basic Information
| Provider Information | |||||||||
| NPI: | 1093777278 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC ORAL PATHOLOGY LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
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| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159296572 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | EVERSOLE | ||||||||
| AuthorizedOfficialFirstName: | LEWIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4159296572 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 292200000X | Y | Laboratories | Dental Laboratory |
ID Information
| ID | Type | State | Issuer | Description | LAB64366F | 05 | CA | MEDICAID |