Provider Demographics
NPI:1003085036
Name:GISH, JOSHUA ETHAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ETHAN
Last Name:GISH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:260 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:BLDG 2, SUITE 12
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784
Mailing Address - Country:US
Mailing Address - Phone:631-696-9752
Mailing Address - Fax:631-696-5096
Practice Address - Street 1:260 MIDDLE COUNTRY ROAD
Practice Address - Street 2:BLDG 2, SUITE 12
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784
Practice Address - Country:US
Practice Address - Phone:631-696-9752
Practice Address - Fax:631-696-5096
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-24
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY053598-11223S0112X
NY053598204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery