Provider Demographics
NPI:1699119552
Name:GALLOTTA, DOMINIQUE J (LAC)
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:J
Last Name:GALLOTTA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:DOMINIQUE
Other - Middle Name:J
Other - Last Name:GALLOTTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:236 S LARCHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3711
Mailing Address - Country:US
Mailing Address - Phone:323-377-2072
Mailing Address - Fax:
Practice Address - Street 1:236 S LARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3711
Practice Address - Country:US
Practice Address - Phone:323-377-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6769208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice