Provider Demographics
NPI:1558666339
Name:TA GEREB ORTHODONTICS, INC.
Entity Type:Organization
Organization Name:TA GEREB ORTHODONTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEREB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-698-5121
Mailing Address - Street 1:5121 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-5103
Mailing Address - Country:US
Mailing Address - Phone:619-698-5121
Mailing Address - Fax:619-698-1229
Practice Address - Street 1:5121 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5103
Practice Address - Country:US
Practice Address - Phone:619-698-5121
Practice Address - Fax:619-698-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40153261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental