Provider Demographics
NPI:1407921703
Name:BISHOP, GARY DENNIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DENNIS
Last Name:BISHOP
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 1:615 N WALNUT ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3811
Mailing Address - Country:US
Mailing Address - Phone:812-332-8290
Mailing Address - Fax:
Practice Address - Street 1:615 N WALNUT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3811
Practice Address - Country:US
Practice Address - Phone:812-332-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist