MEDICARE: DR. TRACY G GOLDEN D.M.D.

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	1223P0300X	Periodontics	33208	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33208	OTHER	CA	LICENSE NUMBER

General Provider Information

NPI Number	:	1093741183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY G GOLDEN D.M.D.

Provider Business Mailing Address
First Line	:	10921 WILSHIRE BLVD
Second Line	:	1009
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-3906
Country	:	US
Telephone Number	:	310-209-7572
Fax Number	:	310-209-7574

Provider Business Practice Location Address
First Line	:	10921 WILSHIRE BLVD
Second Line	:	1009
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-3906
Country	:	US
Telephone Number	:	310-209-7572
Fax Number	:	310-209-7574

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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