Healthcare Provider Details

I. General information

NPI: 1699506154
Provider Name (Legal Business Name): ETHAN CO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W LAS TUNAS DR STE 107
SAN GABRIEL CA
91776-1236
US

IV. Provider business mailing address

5049 PRINCESS ANNE RD
LA CANADA CA
91011-2424
US

V. Phone/Fax

Practice location:
  • Phone: 626-872-6352
  • Fax:
Mailing address:
  • Phone: 818-415-6578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: