MEDICARE: GALLO MICHELS PROFESSIONAL DENTAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	31040	CA

General Provider Information

NPI Number	:	1386747913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALLO MICHELS PROFESSIONAL DENTAL CORP

Provider Business Mailing Address
First Line	:	10645 TIERRASANTA BLVD
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-2614
Country	:	US
Telephone Number	:	858-277-6080
Fax Number	:	858-277-4773

Provider Business Practice Location Address
First Line	:	10645 TIERRASANTA BLVD
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-2614
Country	:	US
Telephone Number	:	858-277-6080
Fax Number	:	858-277-4773

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	NICOLE REID
Credential	:
Telephone Number	:	619-261-1670

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	08/22/2020

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