Provider Demographics
NPI:1073719373
Name:DORIS A. GUEVARA D.D.S., INC
Entity Type:Organization
Organization Name:DORIS A. GUEVARA D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-330-0604
Mailing Address - Street 1:652 E REGENT ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1415
Mailing Address - Country:US
Mailing Address - Phone:310-330-0604
Mailing Address - Fax:310-330-0590
Practice Address - Street 1:652 E REGENT ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1415
Practice Address - Country:US
Practice Address - Phone:310-330-0604
Practice Address - Fax:310-330-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-23
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9135001Medicaid