Healthcare Provider Details

I. General information

NPI: 1063641256
Provider Name (Legal Business Name): GARY L DEVIAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 YORBA LINDA BLVD SUITE K
YORBA LINDA CA
92886-3810
US

IV. Provider business mailing address

17300 YORBA LINDA BLVD SUITE K
YORBA LINDA CA
92886-3810
US

V. Phone/Fax

Practice location:
  • Phone: 714-524-6111
  • Fax: 714-985-0256
Mailing address:
  • Phone: 714-524-6111
  • Fax: 714-985-0256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: