Provider Demographics
NPI:1164650164
Name:PETER H. BAE D.D.S DENTAL CORP.
Entity Type:Organization
Organization Name:PETER H. BAE D.D.S DENTAL CORP.
Other - Org Name:DENTAL PLAYGROUND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:HYUN
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:DD S
Authorized Official - Phone:323-291-3900
Mailing Address - Street 1:3651 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-4849
Mailing Address - Country:US
Mailing Address - Phone:323-291-3900
Mailing Address - Fax:323-846-1158
Practice Address - Street 1:3651 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4849
Practice Address - Country:US
Practice Address - Phone:323-291-3900
Practice Address - Fax:323-846-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA810623008OtherDENTI-CAL