Provider Demographics
NPI:1477871564
Name:GASSOWAY, VIRGIL
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:
Last Name:GASSOWAY
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 1:605 S CALUMET RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 S CALUMET RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3218
Practice Address - Country:US
Practice Address - Phone:219-926-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006941A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist