Provider Demographics
NPI:1194803247
Name:LOITZ, GREG A (MD DDS)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:A
Last Name:LOITZ
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:33 PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:LA SELVA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1729
Mailing Address - Country:US
Mailing Address - Phone:831-566-1112
Mailing Address - Fax:833-233-3943
Practice Address - Street 1:33 PALMA AVE
Practice Address - Street 2:
Practice Address - City:LA SELVA BEACH
Practice Address - State:CA
Practice Address - Zip Code:95076-1729
Practice Address - Country:US
Practice Address - Phone:831-566-1112
Practice Address - Fax:833-233-3943
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52694204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG52694OtherMEDICAL BOARD OF CALIF
CAD28354OtherDENTAL BOARD OF CALIF