Provider Demographics
NPI:1487851531
Name:KIZZEN, GARY ALEX (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALEX
Last Name:KIZZEN
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 1:1528 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2503
Mailing Address - Country:US
Mailing Address - Phone:440-821-6755
Mailing Address - Fax:440-871-3213
Practice Address - Street 1:20911 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2022
Practice Address - Country:US
Practice Address - Phone:440-821-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30128951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice