Healthcare Provider Details

I. General information

NPI: 1871702027
Provider Name (Legal Business Name): MARTIN NEIL GORMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5363 BALBOA BLVD # 446
ENCINO CA
91316-2805
US

IV. Provider business mailing address

5363 BALBOA BLVD # 446
ENCINO CA
91316-2805
US

V. Phone/Fax

Practice location:
  • Phone: 818-995-1891
  • Fax: 818-995-4309
Mailing address:
  • Phone: 818-995-1891
  • Fax: 818-995-4309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: