Provider Demographics
NPI:1598935181
Name:BOOTS, GREGORY STAN
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:STAN
Last Name:BOOTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7140 DE LONGPRE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4451
Mailing Address - Country:US
Mailing Address - Phone:323-850-7255
Mailing Address - Fax:
Practice Address - Street 1:24423 NARBONNE AVE
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1134
Practice Address - Country:US
Practice Address - Phone:310-326-7231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist