Provider Demographics
NPI:1164643094
Name:GIMLEN, AMY A (DDS MS)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:A
Last Name:GIMLEN
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 MANHATTAN BEACH BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5131
Mailing Address - Country:US
Mailing Address - Phone:310-545-6525
Mailing Address - Fax:310-546-6203
Practice Address - Street 1:973 MANHATTAN BEACH BLVD STE C
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5131
Practice Address - Country:US
Practice Address - Phone:310-545-6525
Practice Address - Fax:310-546-6203
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD53065Medicaid