Provider Demographics
NPI:1780980177
Name:SOLIVEN, SAMUEL GONZALES (DDS)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GONZALES
Last Name:SOLIVEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E GLENOAKS BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-2036
Mailing Address - Country:US
Mailing Address - Phone:954-646-3274
Mailing Address - Fax:
Practice Address - Street 1:125 E GLENOAKS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-2036
Practice Address - Country:US
Practice Address - Phone:954-646-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60063122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice