Provider Demographics
NPI:1457322489
Name:SMISEK, GARY RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RALPH
Last Name:SMISEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1986 SHARONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5437
Mailing Address - Country:US
Mailing Address - Phone:651-636-4063
Mailing Address - Fax:170-776-0457
Practice Address - Street 1:501 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2016
Practice Address - Country:US
Practice Address - Phone:651-483-6747
Practice Address - Fax:707-760-4579
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice