Healthcare Provider Details

I. General information

NPI: 1134785926
Provider Name (Legal Business Name): GABRIEL LEGROS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 W NORTH AVE BLDG D
BROOKFIELD WI
53005-4633
US

IV. Provider business mailing address

12660 W NORTH AVE BLDG D
BROOKFIELD WI
53005-4633
US

V. Phone/Fax

Practice location:
  • Phone: 262-796-1312
  • Fax:
Mailing address:
  • Phone: 262-796-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002043-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: