Provider Demographics
NPI:1073137626
Name:OLAVERRIA SALAVAGGIONE, GONZALO NICOLAS (DDS)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:NICOLAS
Last Name:OLAVERRIA SALAVAGGIONE
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 1:10852 WILKINS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4924
Mailing Address - Country:US
Mailing Address - Phone:314-805-3337
Mailing Address - Fax:
Practice Address - Street 1:10047 MIDLOTHIAN TPKE STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4858
Practice Address - Country:US
Practice Address - Phone:804-510-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417599122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist