Provider Demographics
NPI:1164660379
Name:GALLEGO, DORA ELENA
Entity Type:Individual
Prefix:DR
First Name:DORA
Middle Name:ELENA
Last Name:GALLEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12336 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3508
Mailing Address - Country:US
Mailing Address - Phone:201-919-3164
Mailing Address - Fax:
Practice Address - Street 1:12336 MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3508
Practice Address - Country:US
Practice Address - Phone:201-919-3164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist