Provider Demographics
NPI:1174674964
Name:GRAGEDA, ENRIQUE (DMD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:GRAGEDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10923 BELCHER ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2536
Mailing Address - Country:US
Mailing Address - Phone:562-863-0258
Mailing Address - Fax:
Practice Address - Street 1:PUENTE DE PIEDRA 150-905. COL. TORIELLO GUERRA
Practice Address - Street 2:
Practice Address - City:MEXICO CITY
Practice Address - State:MEXICO
Practice Address - Zip Code:14050
Practice Address - Country:MX
Practice Address - Phone:01152555-606-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA498911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics