Medi-Cal Suspended and Ineligible Provider List




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Medi-Cal Suspended and Ineligible Provider List


Dentist Provider

Numbers


Abdelmalek, Ashraf B33184 Suspended

824 S. Alvarado St. indefinitely effective

Los Angeles, CA 7/12/1991


Abilez, Gilbert J. Jr. Suspended

3180 Willow Ln. indefinitely effective

Ste. #218 4/20/1998

Westlake Village, CA


Abusbitan, Abdulkadir 41576 Suspended

Yousef indefinitely effective

48 Park Plaza Dr. 3/1/2005

Ste. #263

Daly City, CA


Acquaviva, Frederick D., 20982 Suspended

D.D.S. indefinitely effective

120 Happy Valley Rd. 9/27/1990

Santa Cruz, CA


Adams, Karen Leona 90015 Suspended

501 W. Olympic Blvd. indefinitely effective

Apt. #811 12/30/2001

Los Angeles, CA


Adeli, Mojgan E. Suspended

1129 27th St. indefinitely effective

Los Angeles, CA 7/20/1998


Ahn, Steve Sangmoon D47346 Suspended

4340 W. Simmons Ave. indefinitely effective

Orange, CA 2/16/2009


Akop, William D36512 Suspended

1624 Glenmount Dr. indefinitely effective

Glendale, CA 6/17/1998


Albarracin, Carlos Unlicensed Suspended

Business Manager indefinitely effective

37730 53rd St. E. 6/20/2005

Palmdale, CA


Alhanati, Craig B32216 Suspended

4226 S. Saviers Rd. indefinitely effective

Unit #9 6/7/1994

Oxnard, CA


Allen, John Edward B28270 Suspended

3273 Hammonton Rd. indefinitely effective

Marysville, CA 1/20/2010


Dentist Provider

Numbers


Almadi, Hamid Reza 44645-CA Suspended

aka: Hamid Reza Amhadi 3201-NV indefinitely effective

2385 E. Windmill Ln. 9/18/2008

Apt. #263E

Las Vegas, NV


Anderson, Greg B30331 Suspended

6 Red Feather Ct. indefinitely effective

Pleasanton, CA 4/3/1995


Anderson, Mark Kevin 35467 Suspended

aka: Mark K. Anderson indefinitely effective

74 W. Lincoln Ave. 9/28/2007

Woodland, CA


Arcadia Kids Dental Care Suspended

638 W. Duarte Rd. indefinitely effective

Ste. #9 4/20/2005

Arcadia, CA


Atallah, Hassan Suspended

23930 Ocean Ave. indefinitely effective

Unit #15 6/18/1998

Torrance, CA


Badzik, Daniel R. B16463 Suspended

1530 3rd St. indefinitely effective

Ste. #201 6/19/1995

Lincoln, CA


Bae, Michael Yoonbum 27952 Suspended

3540 Wilshire Blvd. D27952 indefinitely effective

Ste. #212 B27952 6/22/2010

Los Angeles, CA

and

2140 W. Olympic Blvd.

Ste. #308

Los Angeles, CA


Baily, Robert C. D15457 Suspended

200 N. Cumbre Rd. indefinitely effective

Ste. G 4/8/1996

Ventura, CA


Ballard, Roger L. B15933 Suspended 30

10862 Calle Verde days effective

Ste. C 4/6/1992

La Mesa, CA


Dentist Provider

Numbers


Banaga, Josefina M., 49277 Suspended

D.D.S. indefinitely effective

Josefina Banaga Dental 6/14/2006

Clinic

1818 S. Western Ave.

Unit #205

Los Angeles, CA

and

1200 N. Vermont Ave.

Ste. D

Los Angeles, CA


Bautista, Maximillian 45822 Suspended

532 Lanning Ct. indefinitely effective

San Jose, CA 4/10/2007


Bautista, Rolando B27954 Suspended

565 E. El Paso indefinitely effective

Fresno, CA 6/17/1996


Bentley, David J. Suspended

380 Waller St. indefinitely effective

San Francisco, CA 10/20/2003


Berkowitz, Ronald, B18680 Suspended

D.D.S. indefinitely effective

2020 Coffee Rd. 7/31/1993

Ste. #J4

Modesto, CA


Berthelsen, Roger Lee 31895 Suspended

180 E. Palm Canyon Dr. indefinitely effective

Palm Springs, CA 10/20/2003 (old date)

4/10/2005 (new date)


Bevan, Warren Alexander 24746 Suspended

2505 Samaritan Dr. indefinitely effective

Ste. #406 6/19/2004

San Jose, CA


Bina, Shokrollah B39233 Suspended

3108 W. Imperial Hwy. indefinitely effective

Inglewood, CA 11/23/1998

Dentist Provider

Numbers


Bingham, Charles B. B10796 Suspended

500 N. Broadway indefinitely effective

Unit #18 9/14/1992

Blythe, CA


Blue, Dennis Royal B24363 Suspended

1245 Main St. indefinitely effective

P.O. Box 2850 7/24/1996

Weaverville, CA


Borja, Benjamin D27240 Suspended

2226 N. Manor Dr. indefinitely effective

Sacramento, CA 5/1/1996


Bradford, John Philip 44657 Suspended

3823 8th Ave. G91575 indefinitely effective

San Diego, CA 3/18/2010


Bregman, Stephanie D. 41358 Suspended

P.O. Box 31 indefinitely effective

Goleta, CA 10/20/2010


Brinker, Richard Suspended

2580 Jacklight Cove indefinitely effective

Port Hueneme, CA 8/12/1996


Burke, Errol, D.D.S. DL19271* Suspended

7080 Hollywood Blvd. indefinitely effective

Unit #1008 7/1/1972

Los Angeles, CA


Butko, Nathaniel K. B38808 Suspended

5814 Jupiter Pl. indefinitely effective

Gardena, CA 2/14/1994


Butler, David S. 20001 Suspended

4236 Bonita Rd. indefinitely effective

Bonita, CA 8/18/2003


Butt, Farida Rashid D38809 Suspended

House #85 indefinitely effective

St. #61 F-10/3 6/18/1998

Islamadad, Pakistan


Dentist Provider

Numbers


Calhoun, Michael D34938 Suspended

1438 Adobe St. indefinitely effective

Palm Springs, CA 4/13/1997


Cambron, Otoniel Unlicensed Suspended

8995 San Gabriel Ave. indefinitely effective

South Gate, CA 6/27/2006


Cano, Felix F. B27508 Suspended

P.O. Box 1064 indefinitely effective

Ceres, CA 11/18/1999


Chang, Hoon Young D41902 Suspended

2413 W. 17th St. B41902-01 indefinitely effective

Santa Ana, CA 2/16/2009


Chang, Steven Sun 39382 Suspended

1721 Artesia Blvd. indefinitely effective

Gardena, CA 11/19/2004


Chapple, Steven Allen, Suspended

D.D.S. indefinitely effective

3172 S. Arcadian 9/20/1998

Shores Rd.

Ontario, CA


Cheng, Samuel K. 21356 Suspended

2001 Barrington Ave. indefinitely effective

Ste. #305 10/24/2001

W. Los Angeles, CA


Ching, Clayton V. B33266 Suspended

146 S. Fairmont Blvd. indefinitely effective

Anaheim, CA 4/2/1997


Christian, Roy Paul 36212 Suspended

990 W. Fremont Ave. indefinitely effective

Ste. #U-2 10/20/2005

Sunnyvale, CA


Choi, Seong Y. Suspended

1575 Kiowa Crest Dr. indefinitely effective

Diamond Bar, CA 6/18/1998


Chung, David Wayne B26612 Suspended

4200 Trabuco Rd. indefinitely effective

Ste. #120 11/9/1993

Irvine, CA


Dentist Provider

Numbers


Cleymaet, Robert Victor 22209 Suspended

9800 Topanga Canyon indefinitely effective

Blvd. 9/19/2002

Ste. #146

Chatsworth, CA


Cline, Darrell E. Suspended

2717 18th S.E. indefinitely effective

Auburn, WA 8/31995


Cole, Edilia Campaneria 32672 Suspended

Folsom Family Dental indefinitely effective

Center 6/22/2002

6611 Folsom-Auburn Rd.

Ste. M

Folsom, CA


Coleman, Harold Jr. Suspended

18851 Goldenwest Dr. indefinitely effective

Huntington, CA 2/20/2011


Collins, Joseph D. 28529 Suspended

1681 N. Waterman Ave. indefinitely effective

San Bernardino, CA 9/17/1992


Comer, Michael J. Suspended

8635 Elk Grove-Florin Rd. indefinitely effective

Elk Grove, CA 12/9/1996


Crane, David Keith 30925 Suspended

259 Meridian Ave. indefinitely effective

Unit #1 6/11/2004

San Jose, CA


Curbelo, Sue Elena Suspended

343 Pioneer Dr. indefinitely effective

Park Towers 9/14/2005

Unit #702

Glendale, CA


Cusimano, Christian C. 35481 Suspended

P.O. Box 1405 indefinitely effective

Brea, CA 3/3/2006


Cutts, David P. B32230 Suspended

40945 County Center Dr. indefinitely effective

Temecula, CA 2/16/1995


Daguplo, Diosdado L. Suspended

15923 Amar Rd. indefinitely effective

La Puente, CA 5/20/2001


Dentist Provider

Numbers


Dahler, Johan P. B22594 Suspended

1460 Washington Blvd. indefinitely effective

Unit B-201 11/12/1993

Concord, CA


Dambrose, Howard 37409 Suspended

10715 Tierrasanta Blvd. indefinitely effective

Ste. C 6/16/2004

San Diego, CA


Dang, Diem not provided Suspended

1344 Runshaw Pl. indefinitely effective

San Jose, CA 5/20/2012



Dansie, H. Boyd 27264 Suspended

1701 W. March Ln. indefinitely effective

Ste. B 9/18/2006

Stockton, CA


Davari, Mehrdad 40569 Suspended

20504 Ventura Blvd. indefinitely effective

Unit #310 9/28/2007

Woodland Hills, CA


Dayan, M. Joshua D34688 Suspended

1450 Cedar Pl. indefinitely effective

Los Altos, CA 1/24/1996


Del Mundo, Librada V., 24713 Suspended

D.D.S. indefinitely effective

1404 N. Alexandria Ave. 8/31/1991

Los Angeles, CA


Delgado, Robert 25694 Suspended

aka: Delgado, Roberto indefinitely effective

217 S. Serrano Ave. 12/29/2001

Unit #1

Los Angeles, CA


Derboghosian, Roberto D31245 Suspended

6801 Woodman Ave. indefinitely effective

Van Nuys, CA 3/14/1997


DiNozzi, Anthony David Suspended

714 Kennedy Way indefinitely effective

Youngwood, Pennsylvania 5/28/2003


Dodson, William Francis 4970 Suspended

880 Cass St. indefinitely effective

Unit #200 6/1/1990

Monterey, CA


Duffin, Steven R., D.D.S. CGP120755 Suspended

41997 Tomahawk Ct. indefinitely effective

Aguanga, CA 5/30/1991


Ebrahimian, Shahab 44473 Suspended

1315 Carla Ln. indefinitely effective

Beverly Hills, CA 9/3/2007


Dentist Provider

Numbers


Edalati, Bahman T. 48103 Suspended

112 Tracy Court indefinitely effective

Alamo, CA 3/20/2007


Ellenberger, John R., 23821 Suspended

D.D.S. indefinitely effective

7107 Arlington Ave. 12/6/1990

Unit #l

Riverside, CA


Engbretson, Wayne Allen 23822 Suspended

15805 Avenida Venusta indefinitely effective

Ste. #516 9/19/2002

San Diego, CA

And

14720 N. Swan

Oro Valley, AZ


Ensminger, Aletha M. 35254 Suspended

c/o 5210 Valhalla Dr. B35254 indefinitely effective

Carmichael, CA 1114076734 8/19/2010


Eslao, Caesar Suspended

23067 Archibald Ave. indefinitely effective

Carsen, CA 2/14/1996


Esmenjaud, Erick 50408 Suspended

Guillermo indefinitely effective

14435 Hamlin St. 5/7/2007

Ste. #208

Van Nuys, CA


Fan, Allen Tso-Chiang 33134 Suspended

871 S. Atlantic Blvd. indefinitely effective

Monterey Park, CA 10/8/2003


Fayngor, Alexander, 31605 Suspended

D.D.S. indefinitely effective

133 N. Swall Dr. 9/22/2004

Unit #102

Beverly Hills, CA


Fayngor, Irina 34093 Suspended

10496 Garvey Ave. indefinitely effective

El Monte, CA 5/14/2003


Feder, Robert Dean 25253 Suspended

4789 Songbird indefinitely effective

Chico, CA 1/22/2002


Fifield, Perry Melvin 22347 Suspended

9457 S. 7000 E. indefinitely effective

Sandy, Utah 8/18/2003


Finley, James 26633 Suspended

3741 Olympiad Dr. indefinitely effective

Los Angeles, CA 9/23/2004


Dentist Provider

Numbers


Flanagan, Hatti M. 13585 Suspended

aka: Foley, Hatti M. indefinitely effective

aka: Flanagan, Hatti 6/5/2005

Maelynne

7985 Santa Monica Blvd.

Ste. #109

West Los Angeles, CA


Fordyce, Robert B12373 Suspended

1214 12th St. indefinitely effective

Modesto, CA 10/23/1992


Formaker, James W. D34487 Suspended

1125 Pico Blvd. indefinitely effective

Unit #203 5/6/1997

Santa Monica, CA


Foster, Craig B25256 Suspended

5000 Bechelli Ln. indefinitely effective

Unit #104 6/23/1992

Redding, CA


Fox, Robert Lee, D.D.S. DC11128* Suspended

3843 Howe St. indefinitely effective

Unit #6 2/20/1975

Oakland, CA


Frankel, Gerard Sydney B14086 Suspended

dba: The Frankel Dental indefinitely effective

Group Family Dentistry 7/14/2001

9460 Beverly Hills Crest Dr.

Beverly Hills, CA


Fredman, Lourya K., D.D.S. DX18323* Suspended

2901 Wilshire Blvd. indefinitely effective

Unit #201 9/21/1974

Santa Monica, CA


Frier, Jill, D.D.S. B30347 Suspended

238 Calle Laureles indefinitely effective

Santa Barbara, CA 12/4/1993

Fritz, Ronald E., D.D.S. 22731 Suspended

P.O. Box 881 indefinitely effective

Rancho Sante Fe, CA 4/6/1990


Froh, John R. 21709 Suspended

6213 Eisenhower Ct. indefinitely effective

Chino, CA 7/20/2001


Gabriel, Tony Suspended

909 E. Windsor Rd. indefinitely effective

Glendale, CA 1/5/1997


Dentist Provider

Numbers


Galvan, Anthony Halili 44173 Suspended

aka: Halili, Anthony Galvan indefinitely effective

Galvan, Anthony Halil 1/20/2006

4700 Tassajara Rd.

Apt. #3410

Dublin, CA

and

21001 San Ramon

Valley Blvd.

Ste. C7

San Ramon, CA


Garcia, Gilberto B37667 Suspended

128 Nieto Ave. indefinitely effective

Long Beach, CA 6/5/1997


Garcia, Miguel A. 37107 Suspended

9334 Birch Bark Ave. indefinitely effective

Downey, CA 5/9/1999


Gentile, Daniel F. 18470 Suspended

11486 Phoebe Ct. indefinitely effective

Penn Valley, CA 6/19/2004


Georgeson, Ronald M. B33090 Suspended

181 S. Madera Ave. indefinitely effective

Kerman, CA 2/19/1998


Gerodias, Eduardo 46799 Suspended

Sabater indefinitely effective

2800 Braden Ave. 1/30/2007

Apt. #211

Modesto, CA


Ghilotti, Frank Robert 28155 Suspended

1110 W. Robinhood Dr. indefinitely effective

Ste. #100 3/3/2006

Stockton, CA


Ghookasian, Vigen G90564-01 Suspended

11904 Darby Ave. G90564-02 indefinitely effective

Northridge, CA G90564-03 10/1/2008

D36543


Goldenberg, Jacob E. Suspended

33000 N. Highway 1 indefinitely effective

Fort Bragg, CA 9/20/2001


Gougaloff, Roberto 40824 Suspended

525 Main St. indefinitely effective

El Segundo, CA 7/27/2004


Grandhi, Ram Kumar 53426 Suspended

11708 Corino Way 1619181633 indefinitely effective

Rancho Cordova, CA 9/20/2010


Dentist Provider

Numbers


Gray, Scott D. 36759 Suspended

550 E. Latham Ave. B36759 indefinitely effective

Ste. #1 1316090533 10/20/2010

Hemet, CA


Greer, David Thomas 32310 Suspended

600 Coffee Rd. indefinitely effective

Ste. P 1/24/2002

Bakersfield, CA


Greethong, Kitiman 39154 Suspended

123 Main St. indefinitely effective

Irvine, CA 2/20/2002


Gruer, Barry Howard 22359 Suspended

2780 Cardinal Rd. indefinitely effective

Ste. B 12/29/2001

San Diego, CA


Guerra, Kimberly Lynn 50363 Suspended

2621 Sheri Ln. indefinitely effective

Lemon Grove, CA 4/10/2005


Gutgarts, Eliozar M. 32312 Suspended

7865 Oceanus Dr. indefinitely effective

Los Angeles, CA 1/24/2002


Gyaami, Opanin N. 33932 Suspended

1012 Keystone Ct. indefinitely effective

Vacaville, CA 7/20/2004


Hakanson, Mark Randall 26860 Suspended

638 W. Duarte Rd. indefinitely effective

Ste. #9 6/19/2003

Arcadia, CA


Hakimpour, Reza B43167-01 Suspended

2390 Hecate Ct. indefinitely effective

San Jose, CA 8/25/2010


Hall, Barry S., D.D.S. B35895 Suspended

500 Calaveras Blvd. indefinitely effective

#341 2/14/1996

Milpitas, CA


Hamer, Robert L. 25897 Suspended

553 Edgetown Ave. indefinitely effective

Oakdale, CA 10/24/2001


Hamilton, Peder H. 24668 Suspended

dba: Hamilton, Peder, indefinitely effective

D.D.S., Inc. 9/20/2001

P.O. Box 111004

Campbell, CA


Dentist Provider

Numbers


Han, Grace Suhui 42322 Suspended

1126 N. Flower St. indefinitely effective

Ste. C 6/20/2001

Santa Ana, CA


Hanna, George 31624 Suspended

30645 Rue De La Pierre indefinitely effective

Los Angeles, CA 4/29/2002


Hanna, Sohair 37334 Suspended

8914 S. Vermont Ave. indefinitely effective

Los Angeles, CA 8/29/2007


Hansen, Robert E. Suspended

aka: Robert E. Hausen indefinitely effective

960 E. Green St. 1/20/1999

Unit #103

Pasadena, CA


Harrell, Walter B24522 Suspended

72-840 Hwy. 111 indefinitely effective

Ste. #397 12/15/1995

Palm Desert, CA


Harrison, Rodney B. B33093 Suspended

540 Wesley Way D33093 indefinitely effective

Claremont, CA 2/27/2009


Harvey, Edward Lee 23193 Suspended

744 Empire St. C indefinitely effective

Ste. #103 12/20/1998

Fairfield, CA


Hashemi, Keyvan 39645 Suspended

c/o 1087 Meredian Ave. indefinitely effective

Ste. #30 11/20/2006

San Jose, CA


Hassapakis, Craig L. Suspended

2525 Iowa Ave. indefinitely effective

Modesto, CA 7/19/2001


Hearvey, Rundal R. B30392 Suspended

P.O. Box 3812 indefinitely effective

Pinedale, CA 12/4/1994


Heller, Louis N., D.D.S. 8181 Suspended

2506 American River Dr. indefinitely effective

Sacramento, CA 7/30/1991


Dentist Provider

Numbers


Hempel, Jeffrey D29290 Suspended

33710 Santiago Rd. B29290 indefinitely effective

Acton, CA 7/20/2008


Hess, Milton W. B11258 Suspended

8809 Sunland Blvd. indefinitely effective

Sun Valley, CA 9/14/1992


Higbee, Barry Tod D33589 Suspended

24515 Alessandro Blvd. indefinitely effective

Sunnymead, CA 10/26/1992


Hobson, Donald A. 33099 Suspended

107 W. Fairview Blvd. indefinitely effective

Inglewood, CA 4/18/2002


Hoehn, James D. B33937 Suspended

280 N.W. Lake Blvd. indefinitely effective

Unit #205 8/29/1995

West Lake Village, CA


Hoffman, Ralph L., D.D.S. 14774 Suspended

3769 San Rafael Way indefinitely effective

Riverside, CA 9/21/1990


Hopenstand, Boaz Jacob Suspended

151 N. Willaman Dr. indefinitely effective

Beverly Hills, CA 4/18/2002


Hosson, Victor B17935 Suspended

4501 Trenton Rd. indefinitely effective

Santa Rosa, CA 10/18/1995


Hovis, Paul K. 019-018316 Suspended

7918 Reseda Blvd. indefinitely effective

Apt. #202 8/20/2001

Reseda, CA


Hudson, Tedie L. Marth Suspended

1340 Granada Ave. indefinitely effective

San Marino, CA 6/27/1996


Ichiuju, Arnold T. Suspended

17 San Marcos Ct. indefinitely effective

Salinas, CA 7/19/2001


Dentist Provider

Numbers


Issacson, Yoram B38298 Suspended

750 W. Alosta Ave. indefinitely effective

Ste. F 11/12/1999

Glendora, CA


Jacobson, Dennis G. 38299 Suspended

240 Newport Center Dr. indefinitely effective

Ste. #105 3/3/2006

Newport Beach, CA


Jensen, Neil B18567 Suspended

8515 Hans Engle Way indefinitely effective

Fair Oaks, CA 11/12/1993


Jimenez, Marcelo B31291 Suspended

1024 S. Glendale Ave. indefinitely effective

Ste. A 9/14/1992

West Covina, CA


Johnson, Liza B30076 Suspended

2643 Scotts Victor Dr. indefinitely effective

Moreno Valley, CA 10/11/1995


Johnson, Robert S. 18715 Suspended

72551 Greenbriar Ln. indefinitely effective

Palm Desert, CA 11/18/2001


Jones, Bradley C. 37678 Suspended

1600 Trancas St. indefinitely effective

Napa, CA 11/7/2004 (old date)

and 11/19/2004 (new date)

1600 Trancas St.

Ste. B

Napa, CA


Ju, Yue Suspended

178 Crestwood Dr. indefinitely effective

Apt. #6 10/20/2003

Daly City, CA


Kalili, Kambiz Tom 35403 Suspended

416 N. Bedford Dr. B34350 indefinitely effective

Ste. #102A 1063671758 7/20/2011

Beverly Hills, CA


Kane, Burton Suspended

28731 Shire Oaks Dr. indefinitely effective

Rancho Palos Verdes, CA 4/20/1998


Dentist Provider

Numbers


Kanemura, Gary Kazuo, 29960 Suspended

D.D.S. indefinitely effective

630 S. Fairmont Ave. 7/14/2004

Ste. A

Lodi, CA


Kazemipour, Reza M. Suspended

1006 Judson Dr. indefinitely effective

Mountain View, CA 10/20/2003


Kelly, Andrew E. B35919 Suspended

dba: Kelly Dental Group indefinitely effective

6005 Le Doux Rd. 4/13/1997

Los Angeles, CA


Kelly, Pedapoodi J. B29323 Suspended

130 N. Las Lunas St. indefinitely effective

Hemet, CA 2/27/1995


Kelly, Pedapoodi Judson 29323 Suspended

4816 Avenue N. indefinitely effective

Apt. #1 7/1/2006

Brooklyn, NY


Kennedy, Bill William 31646 Suspended

5415 S. Chariton Ave. indefinitely effective

Los Angeles, CA 3/4/2003


Kent, Donald E. 34133 Suspended

c/o Over 60 Health Center B34133 indefinitely effective

1006 Myrtle Pl. 4/23/1997 (old date)

Novato, CA 2/10/1999 (new date)

1860 Alcatraz Ave.

Berkeley, CA


Kersten, Timothy Alan 26190 Suspended

20484 Marquette St. indefinitely effective

Burney, CA 11/26/2002


Ketchum, Thomas A. B22236 Suspended

74-965 Highway 111 indefinitely effective

Indian Wells, CA 6/3/1994


Khajavi, Azadeh 46841 Suspended

13455 Granite Creek Rd. indefinitely effective

San Diego, CA 3/3/2006


Dentist Provider

Numbers

  1   2   3

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