Provider Demographics
NPI:1154874162
Name:GOUDA DENTAL CORPORATION
Entity type:Organization
Organization Name:GOUDA DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANABERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-782-9297
Mailing Address - Street 1:5452 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1618
Mailing Address - Country:US
Mailing Address - Phone:661-322-2300
Mailing Address - Fax:661-322-2350
Practice Address - Street 1:5452 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1618
Practice Address - Country:US
Practice Address - Phone:661-322-2300
Practice Address - Fax:661-322-2350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOUDA DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8963601Medicare PIN