Provider Demographics
NPI:1417194051
Name:GABUYA, NINO HERALD CHAN (RDA)
Entity Type:Individual
Prefix:
First Name:NINO HERALD
Middle Name:CHAN
Last Name:GABUYA
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30711 GANADO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6279
Mailing Address - Country:US
Mailing Address - Phone:562-726-5553
Mailing Address - Fax:
Practice Address - Street 1:21229 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5501
Practice Address - Country:US
Practice Address - Phone:310-792-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65717126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA65717OtherRDA LICENCES