Provider Demographics
NPI:1497705909
Name:GENTUSO, JOHN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:GENTUSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0 GOVERNORS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3025
Mailing Address - Country:US
Mailing Address - Phone:781-395-5629
Mailing Address - Fax:781-395-5863
Practice Address - Street 1:0 GOVERNORS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3025
Practice Address - Country:US
Practice Address - Phone:781-395-5629
Practice Address - Fax:781-395-5863
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice