MEDICARE: LAUREL EVELYN LOOMER R.D.H.A.P.

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	124Q00000X	Dental Hygienist	161	CA

General Provider Information

NPI Number	:	1396802518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL EVELYN LOOMER R.D.H.A.P.

Provider Business Mailing Address
First Line	:	PO BOX 899
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95031-0899
Country	:	US
Telephone Number	:	408-358-0209
Fax Number	:	408-358-0209

Provider Business Practice Location Address
First Line	:	16470 W LA CHIQUITA AVE
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95032-4635
Country	:	US
Telephone Number	:	408-358-0209
Fax Number	:	408-358-0209

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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