Healthcare Provider Details

I. General information

NPI: 1750549291
Provider Name (Legal Business Name): GINA DEEB D.D.S., A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 05/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 RIVERSIDE DR SUITE 240
VALLEY VILLAGE CA
91607-3429
US

IV. Provider business mailing address

4570 CHARMION LN
ENCINO CA
91316-3958
US

V. Phone/Fax

Practice location:
  • Phone: 818-760-8966
  • Fax:
Mailing address:
  • Phone: 213-598-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number38984
License Number StateCA

VIII. Authorized Official

Name: DR. GINA DEEB
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 213-598-7000