Provider Demographics
NPI:1194350058
Name:GALLEGOS, FAVIO JR (DDS)
Entity type:Individual
Prefix:DR
First Name:FAVIO
Middle Name:
Last Name:GALLEGOS
Suffix:JR
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 1:18115 GAULT ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4538
Mailing Address - Country:US
Mailing Address - Phone:818-614-8773
Mailing Address - Fax:
Practice Address - Street 1:2239 N SCHOOL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-2539
Practice Address - Country:US
Practice Address - Phone:818-614-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty