Provider Demographics
NPI:1407912181
Name:DAGOSTINO, JOHN R (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DAGOSTINO
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 1:15925 EAST GALE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HACIENDA HIEGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745
Mailing Address - Country:US
Mailing Address - Phone:626-336-6401
Mailing Address - Fax:626-336-5394
Practice Address - Street 1:15925 EAST GALE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HACIENDA HIEGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-336-6401
Practice Address - Fax:626-336-5394
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3042701OtherMEDICAL #