Provider Demographics
NPI:1275541138
Name:GERODIAS, EDUARDO S (DMD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:S
Last Name:GERODIAS
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 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-526-4244
Mailing Address - Fax:209-526-0112
Practice Address - Street 1:220 STANDIFORD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-526-4244
Practice Address - Fax:209-526-0112
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist