Provider Demographics
NPI:1235463688
Name:DR. SUSAN S. GOMEZ-BABA
Entity Type:Organization
Organization Name:DR. SUSAN S. GOMEZ-BABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOMEZ-BABA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-660-8778
Mailing Address - Street 1:330 N VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3511
Practice Address - Country:US
Practice Address - Phone:323-660-8778
Practice Address - Fax:323-660-8779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN S. GOMEZ-BABA, DMD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36545261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36545-02OtherDENTI-CAL