Provider Demographics
NPI:1508066143
Name:NAVARRETE, GREG ISMAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:ISMAEL
Last Name:NAVARRETE
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 1:12804 LA MIRADA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2215
Mailing Address - Country:US
Mailing Address - Phone:562-947-9647
Mailing Address - Fax:562-947-4048
Practice Address - Street 1:12804 LA MIRADA BLVD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2215
Practice Address - Country:US
Practice Address - Phone:562-947-9647
Practice Address - Fax:562-947-4048
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA034172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist