Healthcare Provider Details

I. General information

NPI: 1417954801
Provider Name (Legal Business Name): DOWNEY ORTHODONTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 LAKEWOOD BLVD
DOWNEY CA
90241-2709
US

IV. Provider business mailing address

10501 LAKEWOOD BLVD
DOWNEY CA
90241-2709
US

V. Phone/Fax

Practice location:
  • Phone: 562-869-4318
  • Fax: 562-861-8350
Mailing address:
  • Phone: 562-869-4318
  • Fax: 562-861-8350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number17684
License Number StateCA

VIII. Authorized Official

Name: DR. GEORGE S. GHOLDOIAN
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 562-869-4318