Provider Demographics
NPI:1629259080
Name:GONZALO ECHARTE PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:GONZALO ECHARTE PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHARTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-483-1221
Mailing Address - Street 1:525 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2903
Mailing Address - Country:US
Mailing Address - Phone:212-483-1221
Mailing Address - Fax:
Practice Address - Street 1:525 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2903
Practice Address - Country:US
Practice Address - Phone:212-483-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93205OtherMEDICARE