Provider Demographics
NPI:1073714085
Name:GALLEGOS, DENISE PATRICIA (RDA)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:PATRICIA
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:MISS
Other - First Name:DENISE
Other - Middle Name:PATRICIA
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDA
Mailing Address - Street 1:1538 BURRARD AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90022-5403
Mailing Address - Country:US
Mailing Address - Phone:323-620-0594
Mailing Address - Fax:
Practice Address - Street 1:1538 BURRARD AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5403
Practice Address - Country:US
Practice Address - Phone:323-620-0594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58886126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA58886OtherREGISTERED DENTAL ASSISTA