MEDICARE: PETER H. BAE D.D.S DENTAL CORP.

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	122300000X	Dentist	50034	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	810623008	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1164650164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER H. BAE D.D.S DENTAL CORP.

Provider Business Mailing Address
First Line	:	3651 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-4849
Country	:	US
Telephone Number	:	323-291-3900
Fax Number	:	323-846-1158

Provider Business Practice Location Address
First Line	:	3651 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-4849
Country	:	US
Telephone Number	:	323-291-3900
Fax Number	:	323-846-1158

Authorized Official
Title or Position	:	OWNER/ DENTIST
Name	:	DR. PETER HYUN BAE
Credential	:	D.D. S
Telephone Number	:	323-291-3900

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	06/29/2009

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