Provider Demographics
NPI:1093141897
Name:IMM, GARY R (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:IMM
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 1:1758 BALTIMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7109
Mailing Address - Country:US
Mailing Address - Phone:410-848-9070
Mailing Address - Fax:410-848-7485
Practice Address - Street 1:1758 BALTIMORE BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7109
Practice Address - Country:US
Practice Address - Phone:410-848-9070
Practice Address - Fax:410-848-7485
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist