Provider Demographics
NPI:1558901934
Name:DE GRAKOVAC, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DE GRAKOVAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6553 WINNETKA AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-4247
Mailing Address - Country:US
Mailing Address - Phone:818-422-5686
Mailing Address - Fax:
Practice Address - Street 1:12121 WILSHIRE BLVD STE 1111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1188
Practice Address - Country:US
Practice Address - Phone:310-920-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
57852126800000X
CA57852126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant