Provider Demographics
NPI:1023203387
Name:SHAIN, GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SHAIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35901 CATHEDRAL CANYON DR UNIT 25
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7260
Mailing Address - Country:US
Mailing Address - Phone:253-212-5248
Mailing Address - Fax:
Practice Address - Street 1:81735 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5414
Practice Address - Country:US
Practice Address - Phone:760-391-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA381311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38131OtherPROVIDER LICENSE NUMBER