Provider Demographics
NPI:1730792797
Name:PATAO, DEREK HENRY (DDS)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:HENRY
Last Name:PATAO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 N BRAND BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2905
Mailing Address - Country:US
Mailing Address - Phone:818-843-4322
Mailing Address - Fax:
Practice Address - Street 1:932 N BRAND BLVD STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2905
Practice Address - Country:US
Practice Address - Phone:818-843-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1053891223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice