Healthcare Provider Details

I. General information

NPI: 1174763551
Provider Name (Legal Business Name): MICHAEL GOREN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14515 1/2 VICTORY BLVD
VAN NUYS CA
91411-1619
US

IV. Provider business mailing address

14515 1/2 VICTORY BLVD
VAN NUYS CA
91411-1619
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-9999
  • Fax: 818-902-9393
Mailing address:
  • Phone: 818-902-9999
  • Fax: 818-902-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number53907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: