Healthcare Provider Details

I. General information

NPI: 1174352702
Provider Name (Legal Business Name): BARDI-SAGONG DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 LONG BEACH BLVD
LONG BEACH CA
90807-2003
US

IV. Provider business mailing address

4241 LONG BEACH BLVD
LONG BEACH CA
90807-2003
US

V. Phone/Fax

Practice location:
  • Phone: 562-612-4320
  • Fax: 562-612-4203
Mailing address:
  • Phone: 562-612-4320
  • Fax: 562-612-4203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: LISA KUNG
Title or Position: MANAGER
Credential:
Phone: 310-780-5278