Provider Demographics
NPI:1568679280
Name:GOMEZ-BABA, SUSAN SIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SIA
Last Name:GOMEZ-BABA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:S
Other - Last Name:BABA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
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:323-660-8778
Mailing Address - Fax:323-660-8779
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36545OtherCA LICENSE NO
CAB365452OtherDENTI-CAL PROVIDERNO