Provider Demographics
NPI:1760574206
Name:COONS, GARY LEE
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:COONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9179 N COUNTY RD 25A
Mailing Address - Street 2:BLDG 2A
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356
Mailing Address - Country:US
Mailing Address - Phone:937-778-1309
Mailing Address - Fax:937-778-9200
Practice Address - Street 1:9179 N COUNTY RD 25A
Practice Address - Street 2:BLDG 2A
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356
Practice Address - Country:US
Practice Address - Phone:937-778-1309
Practice Address - Fax:937-778-9200
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30015032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist