Provider Demographics
NPI:1760564835
Name:GILLINGHAM, CARY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:J
Last Name:GILLINGHAM
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 1:101 OAKRIDGE CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4100
Mailing Address - Country:US
Mailing Address - Phone:920-261-5400
Mailing Address - Fax:920-261-1590
Practice Address - Street 1:101 OAKRIDGE CT
Practice Address - Street 2:SUITE C
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4100
Practice Address - Country:US
Practice Address - Phone:920-261-5400
Practice Address - Fax:920-261-1590
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50018621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33354400Medicaid