Provider Demographics
NPI:1568572097
Name:DISANTO-ROSE, GARY ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALLEN
Last Name:DISANTO-ROSE
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 1:32 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-2333
Mailing Address - Country:US
Mailing Address - Phone:518-762-7033
Mailing Address - Fax:518-762-7554
Practice Address - Street 1:32 S MARKET ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2333
Practice Address - Country:US
Practice Address - Phone:518-762-7033
Practice Address - Fax:518-762-7554
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0347941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice