Healthcare Provider Details

I. General information

NPI: 1598488470
Provider Name (Legal Business Name): JUSTIN GHIAM, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11762 FIRESTONE BLVD
NORWALK CA
90650-2898
US

IV. Provider business mailing address

11762 FIRESTONE BLVD
NORWALK CA
90650-2898
US

V. Phone/Fax

Practice location:
  • Phone: 562-667-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN GHIAM
Title or Position: PRESIDENT
Credential: DDS
Phone: 424-281-9956