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General NPI Number Information
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NPI Number | 1265640635
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Entity Type | Individual
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Provider Name | GREGG ALAN TARTAKOW D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 04/12/2012
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Provider Practice Location Address
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Address Line | 4712 ADMIRALTY WAY UNIT 675
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6905
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Country | US
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Telephone | 310-728-9230
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Fax |
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Provider Business Mailing Address
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Address Line | 4712 ADMIRALTY WAY #675
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6905
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Country | US
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Telephone | 310-728-9230
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 54076
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License Number State | CA
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