Provider Demographics
NPI:1336827641
Name:GIL DE CASTRO JORGE, FABIANA (DDS)
Entity Type:Individual
Prefix:
First Name:FABIANA
Middle Name:
Last Name:GIL DE CASTRO JORGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10269 SANTA MONICA BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-6458
Mailing Address - Country:US
Mailing Address - Phone:310-662-1807
Mailing Address - Fax:
Practice Address - Street 1:1692 E GREEN SAGE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93730-8861
Practice Address - Country:US
Practice Address - Phone:310-662-1807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0343131223G0001X
CA1094371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice