Provider Demographics
NPI:1083748149
Name:GILBERT, JAN WADE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:WADE
Last Name:GILBERT
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 1:176 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1731
Mailing Address - Country:US
Mailing Address - Phone:516-239-3333
Mailing Address - Fax:516-371-6940
Practice Address - Street 1:176 BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1731
Practice Address - Country:US
Practice Address - Phone:516-239-3333
Practice Address - Fax:516-371-6940
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist