Provider Demographics
NPI:1639316250
Name:DR. JACK L. GISH & ASSOCIATES, PC
Entity Type:Organization
Organization Name:DR. JACK L. GISH & ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:GISH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-743-4770
Mailing Address - Street 1:85 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5635
Mailing Address - Country:US
Mailing Address - Phone:203-743-4770
Mailing Address - Fax:203-790-5172
Practice Address - Street 1:85 NORTH ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5635
Practice Address - Country:US
Practice Address - Phone:203-743-4770
Practice Address - Fax:203-790-5172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT52391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty