Provider Demographics
NPI:1457488892
Name:WIDDISON, GARY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:WIDDISON
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 1:423 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LV
Mailing Address - State:NV
Mailing Address - Zip Code:89101-4026
Mailing Address - Country:US
Mailing Address - Phone:702-382-1244
Mailing Address - Fax:702-382-6506
Practice Address - Street 1:423 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LV
Practice Address - State:NV
Practice Address - Zip Code:89101-4026
Practice Address - Country:US
Practice Address - Phone:702-382-1244
Practice Address - Fax:702-382-6506
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice