Provider Demographics
NPI:1598070633
Name:LARREA, GABRIEL
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:LARREA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3624
Mailing Address - Country:US
Mailing Address - Phone:818-956-3754
Mailing Address - Fax:
Practice Address - Street 1:6425 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-3624
Practice Address - Country:US
Practice Address - Phone:818-956-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA606831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program