Provider Demographics
NPI:1689722183
Name:MARCOUX, GARY (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MARCOUX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:RUSHFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55971-0746
Mailing Address - Country:US
Mailing Address - Phone:507-864-7773
Mailing Address - Fax:
Practice Address - Street 1:208 S ELM ST
Practice Address - Street 2:
Practice Address - City:RUSHFORD
Practice Address - State:MN
Practice Address - Zip Code:55971
Practice Address - Country:US
Practice Address - Phone:507-864-7773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND107141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice