1235463688 NPI number — DR. SUSAN S. GOMEZ-BABA

Table of content: (NPI 1235463688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235463688 NPI number — DR. SUSAN S. GOMEZ-BABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. SUSAN S. GOMEZ-BABA
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:
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:
1235463688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 N VERMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90004-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N VERMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90004-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-660-8778
Provider Business Practice Location Address Fax Number:
323-660-8779
Provider Enumeration Date:
10/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ-BABA
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
323-660-8778

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  36545 , 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)

  • Identifier: B36545-02 . This is a "DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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