Provider Demographics
NPI:1225708811
Name:MARCHESE, GREGORY THOMAS (DMD, MPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:MARCHESE
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 MUSCAT CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7285
Mailing Address - Country:US
Mailing Address - Phone:916-572-4690
Mailing Address - Fax:
Practice Address - Street 1:514 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2904
Practice Address - Country:US
Practice Address - Phone:213-533-9428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106902122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice