MEDICARE: DR. SAMUEL GEGAMIAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	58035	CA

General Provider Information

NPI Number	:	1063620383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL GEGAMIAN DMD

Provider Business Mailing Address
First Line	:	336 1/2 N MARIPOSA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4404
Country	:	US
Telephone Number	:	818-276-5603
Fax Number	:

Provider Business Practice Location Address
First Line	:	336 1/2 N MARIPOSA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4404
Country	:	US
Telephone Number	:	818-276-5603
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	10/19/2020

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