Provider Demographics
NPI:1164612107
Name:PERERA, GERARD STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:STEPHEN
Last Name:PERERA
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 1:3839 W 1ST ST
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-4075
Mailing Address - Country:US
Mailing Address - Phone:714-554-5062
Mailing Address - Fax:714-554-5062
Practice Address - Street 1:3839 W 1ST ST
Practice Address - Street 2:SUITE B-1
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-4075
Practice Address - Country:US
Practice Address - Phone:714-554-5062
Practice Address - Fax:714-554-5062
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0339711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB33971-01Medicaid
CABP0207363OtherDEA