Healthcare Provider Details

I. General information

NPI: 1477411254
Provider Name (Legal Business Name): GIDE DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2026
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12217 W PICO BLVD
LOS ANGELES CA
90064-1134
US

IV. Provider business mailing address

12217 W PICO BLVD
LOS ANGELES CA
90064-1134
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9641
  • Fax:
Mailing address:
  • Phone: 310-820-9641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEKSANDAR JOVANOVIC
Title or Position: DOCTOR
Credential: DDS
Phone: 310-820-9641