Provider Demographics
NPI:1639334212
Name:LANDA, GENNADY (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:GENNADY
Middle Name:
Last Name:LANDA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44439 N. 17TH STREET WEST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-945-4040
Mailing Address - Fax:
Practice Address - Street 1:44439 N. 17TH STREET WEST
Practice Address - Street 2:SUITE 102
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-945-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539171223S0112X
CAA115339208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery