Provider Demographics
NPI:1063824878
Name:CARDOSO, GARY (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:CARDOSO
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 1:815 CHENEY HWY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6960
Mailing Address - Country:US
Mailing Address - Phone:321-268-0180
Mailing Address - Fax:
Practice Address - Street 1:815 CHENEY HWY
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6960
Practice Address - Country:US
Practice Address - Phone:321-268-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty