Provider Demographics
NPI:1215050919
Name:GARDINA DENTAL CENTER
Entity type:Organization
Organization Name:GARDINA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-532-7323
Mailing Address - Street 1:15201 S. WESTERN AVE.
Mailing Address - Street 2:
Mailing Address - City:GARDINA
Mailing Address - State:CA
Mailing Address - Zip Code:90249
Mailing Address - Country:US
Mailing Address - Phone:310-532-7323
Mailing Address - Fax:310-532-7774
Practice Address - Street 1:15201 S. WESTERN AVE.
Practice Address - Street 2:
Practice Address - City:GARDINA
Practice Address - State:CA
Practice Address - Zip Code:90249
Practice Address - Country:US
Practice Address - Phone:310-532-7323
Practice Address - Fax:310-532-7774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty