Provider Demographics
NPI:1255333431
Name:DWIGHT, GARY HAROLD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:HAROLD
Last Name:DWIGHT
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 PINE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-9737
Mailing Address - Country:US
Mailing Address - Phone:517-339-1812
Mailing Address - Fax:
Practice Address - Street 1:818 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1308
Practice Address - Country:US
Practice Address - Phone:517-333-9500
Practice Address - Fax:517-333-9509
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID101201223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4045412Medicaid
MI2985740Medicaid
MI5337261Medicare ID - Type Unspecified
MI2985740Medicaid