Provider Demographics
NPI:1720206709
Name:GUSH, ALEC CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEC
Middle Name:CHARLES
Last Name:GUSH
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 1:4760 HOWLETT HILL RD
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-9701
Mailing Address - Country:US
Mailing Address - Phone:315-252-7259
Mailing Address - Fax:315-252-6148
Practice Address - Street 1:2 JAMES ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3457
Practice Address - Country:US
Practice Address - Phone:315-252-7259
Practice Address - Fax:315-252-6148
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0505431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics