Provider Demographics
NPI:1083811574
Name:NAZARENO, GARY O (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:O
Last Name:NAZARENO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 DELBON AVENUE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2014
Mailing Address - Country:US
Mailing Address - Phone:209-634-8559
Mailing Address - Fax:209-634-8550
Practice Address - Street 1:1080 DELBON AVENUE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2014
Practice Address - Country:US
Practice Address - Phone:209-634-8559
Practice Address - Fax:209-634-8550
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680443197OtherTIN NUMBER