=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992001200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN LO D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2011
-----------------------------------------------------
Last Update Date | 02/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 DEEP VALLEY DR SUITE 345
-----------------------------------------------------
City | ROLLING HILLS ESTATES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90274-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-377-4551
-----------------------------------------------------
Fax | 310-541-6042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 DEEP VALLEY DR SUITE 345
-----------------------------------------------------
City | ROLLING HILLS ESTATES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90274-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-377-4551
-----------------------------------------------------
Fax | 310-541-6042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER - PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. JONATHAN H LO
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 310-377-4551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 54926
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------