1568475036 NPI number — DR. JOHN FREDERICK CONRAD D.D.S.

Table of content: DR. JOHN FREDERICK CONRAD D.D.S. (NPI 1568475036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568475036 NPI number — DR. JOHN FREDERICK CONRAD D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONRAD
Provider First Name:
JOHN
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568475036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 PIEDMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94705-2313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-848-8606
Provider Business Mailing Address Fax Number:
510-848-0844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 DURANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94704-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-848-8606
Provider Business Practice Location Address Fax Number:
510-848-0844
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D21441 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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