Healthcare Provider Details

I. General information

NPI: 1558080838
Provider Name (Legal Business Name): LOS GATOS ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14830 LOS GATOS BLVD STE 200
LOS GATOS CA
95032-2053
US

IV. Provider business mailing address

14830 LOS GATOS BLVD STE 200
LOS GATOS CA
95032-2053
US

V. Phone/Fax

Practice location:
  • Phone: 408-412-8400
  • Fax: 408-412-5500
Mailing address:
  • Phone: 408-412-8400
  • Fax: 408-412-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: LEE WALKER
Title or Position: PRESIDENT
Credential: MD DDS
Phone: 408-412-8400