Provider Demographics
NPI:1619507779
Name:GERARD WASSELLE DMD LLC
Entity Type:Organization
Organization Name:GERARD WASSELLE DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-223-1013
Mailing Address - Street 1:2440 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4027
Mailing Address - Country:US
Mailing Address - Phone:954-771-1901
Mailing Address - Fax:
Practice Address - Street 1:2480 E COMMERCIAL BLVD, SUITE 2
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3330
Practice Address - Country:US
Practice Address - Phone:954-928-1666
Practice Address - Fax:954-928-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty