Provider Demographics
NPI:1912105917
Name:BURNETT, GREGORY REX (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:REX
Last Name:BURNETT
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 1:54 HERNANDEZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5806
Mailing Address - Country:US
Mailing Address - Phone:408-354-4777
Mailing Address - Fax:
Practice Address - Street 1:150 N JACKSON AVE
Practice Address - Street 2:#211
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1908
Practice Address - Country:US
Practice Address - Phone:408-251-7901
Practice Address - Fax:408-251-0991
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics