Provider Demographics
NPI:1477611432
Name:GUSMEROTTI, GARY LOUIS
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LOUIS
Last Name:GUSMEROTTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:128 OLD ABE ROAD
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-0128
Mailing Address - Country:US
Mailing Address - Phone:715-588-4280
Mailing Address - Fax:
Practice Address - Street 1:128 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-0128
Practice Address - Country:US
Practice Address - Phone:715-588-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022509L1223G0001X
WI55911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice