=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457543472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. GULALAI MATIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4645 FRAZEE RD
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92057-6152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-722-0137
-----------------------------------------------------
Fax | 760-722-2696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4645 FRAZEE RD STE A
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92057-6152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-722-0137
-----------------------------------------------------
Fax | 760-722-8696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 43199
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 43199
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------