MEDICARE: P.H. BAE, 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	50034	CA

General Provider Information

NPI Number	:	1659689016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P.H. BAE, DDS,INC.

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	:

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	:

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

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	10/02/2010

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