=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245382282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GARY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 341 HILLCREST ST
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-691-3263
-----------------------------------------------------
Fax | 562-690-5063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 341 HILLCREST ST
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-691-3263
-----------------------------------------------------
Fax | 562-690-5063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARTHA LESTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-691-3263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------