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General NPI Number Information
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NPI Number | 1164650164
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Entity Type | Organization
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Legal Business Name | PETER H. BAE D.D.S DENTAL CORP.
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Dates
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Enumeration Date | 06/29/2009
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Last Update Date | 06/29/2009
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Provider Practice Location Address
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Address Line | 3651 CRENSHAW BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90016-4849
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Country | US
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Telephone | 323-291-3900
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Fax | 323-846-1158
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Provider Business Mailing Address
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Address Line | 3651 CRENSHAW BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90016-4849
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Country | US
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Telephone | 323-291-3900
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Fax | 323-846-1158
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Authorized Official
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Title or Position | OWNER/ DENTIST
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Name | DR. PETER HYUN BAE
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Credential | D.D. S
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Telephone | 323-291-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 50034
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License Number State | CA
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