Healthcare Provider Details

I. General information

NPI: 1326285727
Provider Name (Legal Business Name): ANTONIO GAMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

IV. Provider business mailing address

445 E HOME ST
LONG BEACH CA
90805-6613
US

V. Phone/Fax

Practice location:
  • Phone: 714-288-1035
  • Fax: 714-288-2784
Mailing address:
  • Phone: 562-422-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number49711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: