Provider Demographics
NPI:1154542017
Name:GALLEGO, MICHAEL F (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:F
Last Name:GALLEGO
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 1:122 BANK ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6520
Mailing Address - Country:US
Mailing Address - Phone:530-273-4814
Mailing Address - Fax:530-273-0179
Practice Address - Street 1:122 BANK ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6520
Practice Address - Country:US
Practice Address - Phone:530-273-4814
Practice Address - Fax:530-273-0179
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23075OtherDENTAL LINCESE