Healthcare Provider Details

I. General information

NPI: 1790798684
Provider Name (Legal Business Name): BAJO DMD & LIWANAG DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 WEST CARSON ST
CARSON CA
90745
US

IV. Provider business mailing address

144 WEST CARSON ST
CARSON CA
90745
US

V. Phone/Fax

Practice location:
  • Phone: 310-835-4088
  • Fax: 310-835-8488
Mailing address:
  • Phone: 310-835-4088
  • Fax: 310-835-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number38963
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number38027
License Number StateCA

VIII. Authorized Official

Name: DR. ELENITA B LIWANAG
Title or Position: DR VP
Credential: DMD
Phone: 310-835-7088