Provider Demographics
NPI:1396035242
Name:BAUM, MELANIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:
Last Name:BAUM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 ROSCOMARE RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-2202
Mailing Address - Country:US
Mailing Address - Phone:310-600-2153
Mailing Address - Fax:
Practice Address - Street 1:1197 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2868
Practice Address - Country:US
Practice Address - Phone:310-600-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0560681223X0400X
CA621461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03474417Medicaid