Provider Demographics
NPI:1891848628
Name:BABOL-BANEZ, GEORGINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGINA
Middle Name:
Last Name:BABOL-BANEZ
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 1:923 N SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1244
Mailing Address - Country:US
Mailing Address - Phone:626-813-1767
Mailing Address - Fax:626-813-1735
Practice Address - Street 1:923 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1244
Practice Address - Country:US
Practice Address - Phone:626-813-1767
Practice Address - Fax:626-813-1735
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39369-01Medicaid
954810444OtherTAX ID