Provider Demographics
NPI:1194849711
Name:MORI, GARY T (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:MORI
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 1:405 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4137
Mailing Address - Country:US
Mailing Address - Phone:323-722-3557
Mailing Address - Fax:323-722-3557
Practice Address - Street 1:10874 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3610
Practice Address - Country:US
Practice Address - Phone:313-837-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice