MEDICARE: SCOTT GOULD NEWHART DMD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30611	CA

General Provider Information

NPI Number	:	1508193236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT GOULD NEWHART DMD, INC.

Provider Business Mailing Address
First Line	:	3516 W IMPERIAL HWY
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2222
Country	:	US
Telephone Number	:	310-550-1533
Fax Number	:	310-330-3688

Provider Business Practice Location Address
First Line	:	3516 W IMPERIAL HWY
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2222
Country	:	US
Telephone Number	:	310-550-1533
Fax Number	:	310-330-3688

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	LYNN NEWHART
Credential	:
Telephone Number	:	310-550-1533

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	11/18/2009

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