=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902574346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA GALLUP DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2021
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 WESTWOOD PLAZA SUITE 222
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-220-0486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 N ORANGE ST UNIT 535
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-5519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-622-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 106613
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------