Provider Demographics
NPI:1316223670
Name:TISCH, GARY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:TISCH
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 1:20475 FARNSLEIGH ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHAKER HTS.
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-751-5555
Mailing Address - Fax:216-757-5556
Practice Address - Street 1:20475 FARNSLEIGH ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:SHAKER HTS.
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-751-5555
Practice Address - Fax:216-757-5556
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-62501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice