Provider Demographics
NPI:1235544958
Name:GINO A GISMONDI DDS PLLC
Entity Type:Organization
Organization Name:GINO A GISMONDI DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:VILAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-622-4828
Mailing Address - Street 1:700 W PIKE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2696
Mailing Address - Country:US
Mailing Address - Phone:304-622-4828
Mailing Address - Fax:304-624-0977
Practice Address - Street 1:700 W PIKE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2696
Practice Address - Country:US
Practice Address - Phone:304-622-4828
Practice Address - Fax:304-624-0977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV37811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026369Medicaid
WV3073126OtherUNITED CONCORDIA
WV3910006064OtherMEDICAID GROUP
WV001750853OtherUNITED CONCORDIA
WV3810000420Medicaid