1063646289 NPI number — GARY ALBERT VANGRINSVEN D.D.S.

Table of content: GARY ALBERT VANGRINSVEN D.D.S. (NPI 1063646289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063646289 NPI number — GARY ALBERT VANGRINSVEN D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANGRINSVEN
Provider First Name:
GARY
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063646289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25228 SUMMERHILL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEVENSON RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91381-2261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-254-0697
Provider Business Mailing Address Fax Number:
661-254-0697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23734 VALENCIA BLVD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
VALENCIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91355-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-253-2200
Provider Business Practice Location Address Fax Number:
661-253-2220
Provider Enumeration Date:
05/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  33529 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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