Healthcare Provider Details

I. General information

NPI: 1750714119
Provider Name (Legal Business Name): MELINDA PIEGA GORDON D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16935 VANOWEN ST SUITE A
LAKE BALBOA CA
91406-4595
US

IV. Provider business mailing address

16935 VANOWEN ST SUITE A
LAKE BALBOA CA
91406-4595
US

V. Phone/Fax

Practice location:
  • Phone: 818-705-2931
  • Fax: 818-705-2931
Mailing address:
  • Phone: 818-705-2931
  • Fax: 818-344-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: