Provider Demographics
NPI:1801369525
Name:GABRIEL J LARREA DMD A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:GABRIEL J LARREA DMD A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:LARREA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-956-3754
Mailing Address - Street 1:6425 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3624
Mailing Address - Country:US
Mailing Address - Phone:818-956-3754
Mailing Address - Fax:
Practice Address - Street 1:6425 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-3624
Practice Address - Country:US
Practice Address - Phone:818-956-3754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty