Healthcare Provider Details

I. General information

NPI: 1730792797
Provider Name (Legal Business Name): DEREK HENRY PATAO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N BRAND BLVD STE A
GLENDALE CA
91202-2905
US

IV. Provider business mailing address

932 N BRAND BLVD STE A
GLENDALE CA
91202-2905
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-4322
  • Fax:
Mailing address:
  • Phone: 818-843-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105389
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: