Provider Demographics
NPI:1063861607
Name:DE VALES, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:DE VALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 S FEDERAL HWY STE 310
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-3332
Mailing Address - Country:US
Mailing Address - Phone:561-894-4299
Mailing Address - Fax:
Practice Address - Street 1:2275 S FEDERAL HWY STE 310
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-3332
Practice Address - Country:US
Practice Address - Phone:561-894-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN26197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program