Provider Demographics
NPI:1376544205
Name:GIANNINA, GWEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:
Last Name:GIANNINA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-339-1177
Mailing Address - Fax:201-339-2120
Practice Address - Street 1:1173 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3132
Practice Address - Country:US
Practice Address - Phone:201-339-1177
Practice Address - Fax:201-339-2120
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2019-12-13
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2013-04-02
Provider Licenses
StateLicense IDTaxonomies
NY057765122300000X
NJ205181223G0001X
NJ22DI020518001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist