Provider Demographics
NPI:1174507495
Name:GALLO, WILLIAM JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JAMES
Last Name:GALLO
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 BAY ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2489
Mailing Address - Country:US
Mailing Address - Phone:231-347-1601
Mailing Address - Fax:231-347-0330
Practice Address - Street 1:322 BAY ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2489
Practice Address - Country:US
Practice Address - Phone:231-347-1601
Practice Address - Fax:231-347-0330
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0088281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154483014OtherNPI FACILITY
MI0B46032OtherBCBSM GROUP ID
MIWG008828OtherDENTAL LICENSE
MIWG008828OtherDENTAL LICENSE
U22137Medicare UPIN
MIAG6467446OtherDEA NUMBER
MI0B46032Medicare PIN