MEDICARE: NORMA A BACA DDS,INC

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	27866	CA

General Provider Information

NPI Number	:	1487055943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORMA A BACA DDS,INC

Provider Business Mailing Address
First Line	:	1919 BEVERLY BLVD
Second Line	:	SUITE A
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2401
Country	:	US
Telephone Number	:	231-484-2165
Fax Number	:	213-484-0162

Provider Business Practice Location Address
First Line	:	1919 BEVERLY BLVD
Second Line	:	SUITE A
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2401
Country	:	US
Telephone Number	:	231-484-2165
Fax Number	:	213-484-0162

Authorized Official
Title or Position	:	OWNER
Name	:	NORMA AMPARO BACA
Credential	:	DDS
Telephone Number	:	213-484-2165

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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