Healthcare Provider Details

I. General information

NPI: 1669691135
Provider Name (Legal Business Name): EDUARDO GABUTEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22012 AVALON BLVD
CARSON CA
90745-3307
US

IV. Provider business mailing address

22012 AVALON BLVD
CARSON CA
90745-3307
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-8963
  • Fax: 310-834-7312
Mailing address:
  • Phone: 310-834-8963
  • Fax: 310-834-7312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: