MEDICARE: PETER H. BAE DDS. DENTAL CORPORATION

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	1223G0001X	General Practice Dentistry	50034	CA

General Provider Information

NPI Number	:	1083886634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER H. BAE DDS. DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	4425 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2731
Country	:	US
Telephone Number	:	323-846-1158
Fax Number	:

Provider Business Practice Location Address
First Line	:	4425 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2731
Country	:	US
Telephone Number	:	323-846-1158
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER HYUN BAE
Credential	:
Telephone Number	:	323-846-1158

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	06/14/2008

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