Provider Demographics
NPI:1235506312
Name:WESTSIDE PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:WESTSIDE PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-451-5748
Mailing Address - Street 1:1304 15TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1811
Mailing Address - Country:US
Mailing Address - Phone:310-451-5748
Mailing Address - Fax:310-393-9528
Practice Address - Street 1:1304 15TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1811
Practice Address - Country:US
Practice Address - Phone:310-451-5748
Practice Address - Fax:310-393-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392661223P0221X
CA599191223P0221X
CA317421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty