Healthcare Provider Details

I. General information

NPI: 1639752256
Provider Name (Legal Business Name): MATTHEW GELALICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2021
Last Update Date: 06/01/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 HART ST
YUMA AZ
85365
US

IV. Provider business mailing address

2058 MAVERICK CIR
LA VERNE CA
91750-2211
US

V. Phone/Fax

Practice location:
  • Phone: 928-269-7135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011625
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9941
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: