Provider Demographics
NPI:1649969403
Name:RETA DE LA GARZA, LUIS LAURO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:LAURO
Last Name:RETA DE LA GARZA
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 1:1023 HENRY AVE APT I
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-8405
Mailing Address - Country:US
Mailing Address - Phone:805-621-9669
Mailing Address - Fax:
Practice Address - Street 1:620 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5035
Practice Address - Country:US
Practice Address - Phone:805-926-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1086521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice