Provider Demographics
NPI:1730535774
Name:1012 GROUP, INC
Entity type:Organization
Organization Name:1012 GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-458-3727
Mailing Address - Street 1:800 S B ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4271
Mailing Address - Country:US
Mailing Address - Phone:650-458-3727
Mailing Address - Fax:
Practice Address - Street 1:800 S B ST
Practice Address - Street 2:SUITE #200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4271
Practice Address - Country:US
Practice Address - Phone:650-458-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA587671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty