Provider Demographics
NPI:1306975073
Name:PROSTHETIC DENTISTRY
Entity type:Organization
Organization Name:PROSTHETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-956-5162
Mailing Address - Street 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 1636
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-956-5162
Mailing Address - Fax:415-956-0166
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:SUITE 1636
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-956-5162
Practice Address - Fax:415-956-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty