MEDICARE: DOWNTOWN LONG BEACH DENTISTRY, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1992531156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNTOWN LONG BEACH DENTISTRY, INC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	560 PINE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-2316
Country	:	US
Telephone Number	:	562-314-4169
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CONOR JACOBSON
Credential	:
Telephone Number	:	714-845-8890

Provider Enumeration Date	:	09/12/2024
Last Update Date	:	02/11/2025

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