Provider Demographics
NPI:1407521420
Name:DEEP, GAGAN (DMD)
Entity Type:Individual
Prefix:
First Name:GAGAN
Middle Name:
Last Name:DEEP
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 BEDFORD LN APT 146
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-3568
Mailing Address - Country:US
Mailing Address - Phone:909-802-6159
Mailing Address - Fax:
Practice Address - Street 1:1919 SUSQUEHANNA RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-4513
Practice Address - Country:US
Practice Address - Phone:909-802-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0433171223G0001X
CA1086861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice