Provider Demographics
NPI:1558468652
Name:ROSS, GAYLAN KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:GAYLAN
Middle Name:KEITH
Last Name:ROSS
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 1:1290 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2340
Mailing Address - Country:US
Mailing Address - Phone:724-349-5660
Mailing Address - Fax:724-349-5661
Practice Address - Street 1:1290 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2340
Practice Address - Country:US
Practice Address - Phone:724-349-5660
Practice Address - Fax:724-349-5661
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-018712-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice