=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639655129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY BRUMBAUGH DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12121 WILSHIRE BLVD STE 1111
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-1188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-820-0588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 TOMICH RD
-----------------------------------------------------
City | HACIENDA HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91745-6817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-536-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DDS102107
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------