Provider Demographics
NPI:1083814172
Name:GILLEN, GEORGE (DDS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GILLEN
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 1:161 MADISON AVENUE
Mailing Address - Street 2:SUITE 7NW
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5449
Mailing Address - Country:US
Mailing Address - Phone:212-481-3636
Mailing Address - Fax:212-481-7878
Practice Address - Street 1:161 MADISON AVENUE
Practice Address - Street 2:SUITE 7NW
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5449
Practice Address - Country:US
Practice Address - Phone:212-481-3636
Practice Address - Fax:212-481-7878
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00347360Medicaid