Provider Demographics
NPI:1083694020
Name:PROSE, GARY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:PROSE
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 1:322 AOLOA ST
Mailing Address - Street 2:APT 905
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3041
Mailing Address - Country:US
Mailing Address - Phone:808-261-0055
Mailing Address - Fax:
Practice Address - Street 1:322 AOLOA ST
Practice Address - Street 2:APT 905
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3041
Practice Address - Country:US
Practice Address - Phone:808-261-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1049801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice