Healthcare Provider Details

I. General information

NPI: 1952713950
Provider Name (Legal Business Name): GRDENTISTRY GILBERTO OLAGUEDDSAPROFESSIONALCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2014
Last Update Date: 05/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3559 W RAMSEY ST STE C1
BANNING CA
92220-3505
US

IV. Provider business mailing address

3559 W RAMSEY ST STE C1
BANNING CA
92220-3505
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-3993
  • Fax: 951-922-3991
Mailing address:
  • Phone: 951-922-3993
  • Fax: 951-922-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number59467
License Number StateCA

VIII. Authorized Official

Name: DR. GILBERTO OLAGUE
Title or Position: PRESIDENT
Credential: DDS
Phone: 805-404-1451