Provider Demographics
NPI:1215140157
Name:NEGRETE, VICTOR R (DDS)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:R
Last Name:NEGRETE
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 1:1611 MONTANA AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1807
Mailing Address - Country:US
Mailing Address - Phone:310-347-9644
Mailing Address - Fax:
Practice Address - Street 1:1611 MONTANA AVE FL 2
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1807
Practice Address - Country:US
Practice Address - Phone:310-347-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice