Provider Demographics
NPI:1023263407
Name:BALDWIN PARK DENTAL
Entity type:Organization
Organization Name:BALDWIN PARK DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-442-4582
Mailing Address - Street 1:13734 RAMONA BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4021
Mailing Address - Country:US
Mailing Address - Phone:626-960-6616
Mailing Address - Fax:626-337-0047
Practice Address - Street 1:13734 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4021
Practice Address - Country:US
Practice Address - Phone:626-960-6616
Practice Address - Fax:626-337-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27016122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174714547Medicaid