Basic Information
| Provider Information | |||||||||
| NPI: | 1699079491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORAL PATHOLOGY DIAGNOSTICS | ||||||||
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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: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 2440 EDENCREST DR | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370131919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154806800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2011 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6154806800 | ||||||||
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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 | 291U00000X | 44D2016339 | TN | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.