Healthcare Provider Details

I. General information

NPI: 1306454327
Provider Name (Legal Business Name): LUZ EDITH ORTIZ GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14525 LAKEWOOD BLVD STE A
PARAMOUNT CA
90723-3638
US

IV. Provider business mailing address

14101 PARAMOUNT BLVD
PARAMOUNT CA
90723-2607
US

V. Phone/Fax

Practice location:
  • Phone: 562-205-8091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA94499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: