Healthcare Provider Details

I. General information

NPI: 1639204241
Provider Name (Legal Business Name): GARY R. MASSA DDS, MSD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 S SEPULVEDA BLVD SUITE 101
LOS ANGELES CA
90045-3606
US

IV. Provider business mailing address

8930 S SEPULVEDA BLVD SUITE 101
LOS ANGELES CA
90045-3606
US

V. Phone/Fax

Practice location:
  • Phone: 310-342-1399
  • Fax:
Mailing address:
  • Phone: 310-342-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number36261
License Number StateCA

VIII. Authorized Official

Name: DR. GARY R MASSA
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-342-1399