Provider Demographics
NPI:1265640635
Name:TARTAKOW, GREGG ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALAN
Last Name:TARTAKOW
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 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:#675
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-728-9230
Mailing Address - Fax:
Practice Address - Street 1:4712 ADMIRALTY WAY
Practice Address - Street 2:UNIT 675
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6905
Practice Address - Country:US
Practice Address - Phone:310-728-9230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA540761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics