Healthcare Provider Details

I. General information

NPI: 1649476672
Provider Name (Legal Business Name): GABRIEL SAN AGUSTIN GUEVARA D.D.S., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45104 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

8392 VALLEY VIEW ST
BUENA PARK CA
90620-2738
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-2391
  • Fax:
Mailing address:
  • Phone: 714-232-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: