=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912300427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN GABRIEL DENTAL PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2014
-----------------------------------------------------
Last Update Date | 09/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3534 W BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-5786
-----------------------------------------------------
Fax | 323-728-8859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3534 W BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-728-5786
-----------------------------------------------------
Fax | 323-728-8859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARTIN GABRIEL REYES I
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 323-728-5786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 46945
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------