MEDICARE: SAN GABRIEL SUMMIT DENTAL, 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	1223G0001X	General Practice Dentistry	44218	CA

General Provider Information

NPI Number	:	1750421319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN GABRIEL SUMMIT DENTAL, INC.

Provider Business Mailing Address
First Line	:	255 E ORANGE GROVE AVE
Second Line	:	SUITE B
City	:	BURBANK
State	:	CA
Zip	:	91502-1240
Country	:	US
Telephone Number	:	818-557-0964
Fax Number	:	818-848-1038

Provider Business Practice Location Address
First Line	:	255 E ORANGE GROVE AVE
Second Line	:	SUITE B
City	:	BURBANK
State	:	CA
Zip	:	91502-1240
Country	:	US
Telephone Number	:	818-557-0964
Fax Number	:	818-848-1038

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DINA M SAN GABRIEL
Credential	:	D.M.D.
Telephone Number	:	818-557-0964

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	01/29/2015

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