Provider Demographics
NPI:1770672016
Name:GULLO, GARY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:GULLO
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 1:12 CANNOCK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-4107
Mailing Address - Country:US
Mailing Address - Phone:585-223-1793
Mailing Address - Fax:
Practice Address - Street 1:532 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1613
Practice Address - Country:US
Practice Address - Phone:585-424-5160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist