Provider Demographics
NPI:1023229622
Name:LAUREL LOOMER
Entity type:Organization
Organization Name:LAUREL LOOMER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:RDHAP
Authorized Official - Phone:408-358-0209
Mailing Address - Street 1:PO BOX 899
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95031-0899
Mailing Address - Country:US
Mailing Address - Phone:408-358-0209
Mailing Address - Fax:408-358-3670
Practice Address - Street 1:16470 W LA CHIQUITA AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-4635
Practice Address - Country:US
Practice Address - Phone:408-358-0209
Practice Address - Fax:408-358-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA161124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZ89882-01Medicaid