Provider Demographics
NPI:1356834675
Name:GENNADY LANDA, DDS, MD, INC.
Entity Type:Organization
Organization Name:GENNADY LANDA, DDS, MD, INC.
Other - Org Name:ANTELOPE VALLEY ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENNADY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:818-970-0253
Mailing Address - Street 1:44439 17TH ST W STE 102
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2854
Mailing Address - Country:US
Mailing Address - Phone:661-945-4040
Mailing Address - Fax:661-945-9120
Practice Address - Street 1:44439 17TH ST W STE 102
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2854
Practice Address - Country:US
Practice Address - Phone:661-945-4040
Practice Address - Fax:661-945-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty