Provider Demographics
NPI:1104912906
Name:VALACICH, GREGORY (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:VALACICH
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 1:4890 S MISSION RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-1100
Mailing Address - Country:US
Mailing Address - Phone:520-908-8797
Mailing Address - Fax:520-908-8937
Practice Address - Street 1:4890 S MISSION RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-1100
Practice Address - Country:US
Practice Address - Phone:520-908-8797
Practice Address - Fax:520-908-8937
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice