Provider Demographics
NPI:1124429774
Name:SAN GABRIEL, DINA (DMD)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:SAN GABRIEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 E ORANGE GROVE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 E ORANGE GROVE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1240
Practice Address - Country:US
Practice Address - Phone:818-557-0964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist