1154874162 NPI number — GOUDA DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154874162 NPI number — GOUDA DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOUDA DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GOUDA'S FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1154874162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5452 CALIFORNIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93309-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-322-2300
Provider Business Mailing Address Fax Number:
661-322-2350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5452 CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-322-2300
Provider Business Practice Location Address Fax Number:
661-322-2350
Provider Enumeration Date:
07/26/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAMPION
Authorized Official First Name:
ANABERTA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
559-782-9297

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  48456 , 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)