Provider Demographics
NPI:1326052838
Name:GISH, JACK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:GISH
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 1:85 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5635
Mailing Address - Country:US
Mailing Address - Phone:203-743-4770
Mailing Address - Fax:203-790-5172
Practice Address - Street 1:85 NORTH ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5635
Practice Address - Country:US
Practice Address - Phone:203-743-4770
Practice Address - Fax:203-790-5172
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT052391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice