Provider Demographics
NPI:1699111682
Name:GALLO-MICHLES PROFESSIONAL DENTAL CORP.
Entity type:Organization
Organization Name:GALLO-MICHLES PROFESSIONAL DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:XOCHITL
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPARZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-220-7495
Mailing Address - Street 1:5690 N FRESNO ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8332
Mailing Address - Country:US
Mailing Address - Phone:559-436-3470
Mailing Address - Fax:
Practice Address - Street 1:5690 N FRESNO ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8332
Practice Address - Country:US
Practice Address - Phone:559-436-3470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty