Healthcare Provider Details

I. General information

NPI: 1417194051
Provider Name (Legal Business Name): NINO HERALD CHAN GABUYA R.D.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21229 HAWTHORNE BLVD
TORRANCE CA
90503-5501
US

IV. Provider business mailing address

30711 GANADO DR
RANCHO PALOS VERDES CA
90275-6279
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-5600
  • Fax:
Mailing address:
  • Phone: 562-726-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number65717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: