Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 33208 | CA |
NPI | 1093741183 |
---|---|
Provider Name | Dr. Tracy G Golden |
First Address | Los Angeles, CA 90024-3906 |
Second Address | Los Angeles, CA 90024-3906 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33208 | LICENSE NUMBER (01) | CA |