Provider Demographics
NPI:1598958506
Name:GEREB, TODD ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ALAN
Last Name:GEREB
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 1:5120 BALTIMORE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941
Mailing Address - Country:US
Mailing Address - Phone:619-466-0123
Mailing Address - Fax:619-466-1276
Practice Address - Street 1:5120 BALTIMORE DR
Practice Address - Street 2:SUITE D
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941
Practice Address - Country:US
Practice Address - Phone:619-466-0123
Practice Address - Fax:619-466-1276
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA401531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics