Provider Demographics
NPI:1073297255
Name:TANAKA, GABRIEL FORTES (DDS)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:FORTES
Last Name:TANAKA
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 1:525 E 21ST ST APT 323
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3890
Mailing Address - Country:US
Mailing Address - Phone:919-218-6531
Mailing Address - Fax:
Practice Address - Street 1:115 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-1815
Practice Address - Country:US
Practice Address - Phone:704-263-8845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC132971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice