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General NPI Number Information
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NPI Number | 1235506312
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Entity Type | Organization
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Legal Business Name | WESTSIDE PEDIATRIC DENTAL GROUP
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 1304 15TH ST STE 206
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City | SANTA MONICA
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State | CA
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Zip | 90404-1811
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Country | US
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Telephone | 310-451-5748
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Fax | 310-393-9528
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Provider Business Mailing Address
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Address Line | 1304 15TH ST STE 206
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City | SANTA MONICA
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State | CA
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Zip | 90404-1811
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Country | US
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Telephone | 310-451-5748
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Fax | 310-393-9528
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Authorized Official
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Title or Position | OWNER
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Name | DR. EMMANUEL BERNARD GROSS
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Credential | DDS
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Telephone | 310-451-5748
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 59919
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 31742
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 39266
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License Number State | CA
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