Provider Demographics
NPI:1467833194
Name:GLEASON, MARCELLA AMANDA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARCELLA
Middle Name:AMANDA
Last Name:GLEASON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:AMANDA
Other - Last Name:TROMBLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3621 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-5233
Mailing Address - Country:US
Mailing Address - Phone:502-235-8007
Mailing Address - Fax:
Practice Address - Street 1:201 TOWNE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:844-223-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9582122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1467833194Medicaid