Healthcare Provider Details

I. General information

NPI: 1639334212
Provider Name (Legal Business Name): GENNADY LANDA DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44441 16TH ST W STE 103
LANCASTER CA
93534-2873
US

IV. Provider business mailing address

44441 16TH ST W STE 103
LANCASTER CA
93534-2873
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-4040
  • Fax:
Mailing address:
  • Phone: 661-945-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA115339
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number53917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: