Healthcare Provider Details

I. General information

NPI: 1174674964
Provider Name (Legal Business Name): ENRIQUE GRAGEDA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PUENTE DE PIEDRA 150-905. COL. TORIELLO GUERRA
MEXICO CITY MEXICO
14050
MX

IV. Provider business mailing address

10923 BELCHER ST
NORWALK CA
90650-2536
US

V. Phone/Fax

Practice location:
  • Phone: 011525556061901
  • Fax:
Mailing address:
  • Phone: 562-863-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number49891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: