1750406377 NPI number — DR. LORETTA GILMORE D.D.S.

Table of content: JAIME ANDRES DAZA FAWCETT MD (NPI 1750538856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750406377 NPI number — DR. LORETTA GILMORE D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
LORETTA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LORETTA GILMORE DENTAL CORPORATION
Provider Other First Name:
LORETTA GILMORE DDS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750406377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9275 BASELINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91730-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-917-4062
Provider Business Mailing Address Fax Number:
888-713-1198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9275 BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-945-0024
Provider Business Practice Location Address Fax Number:
909-948-0506
Provider Enumeration Date:
03/20/2007

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: 1223S0112X , with the licence number:  29281 , 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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