Provider Demographics
NPI:1801816129
Name:ROSS, GARY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:ROSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3416
Mailing Address - Country:US
Mailing Address - Phone:203-393-1570
Mailing Address - Fax:
Practice Address - Street 1:11 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:CT
Practice Address - Zip Code:06524-3416
Practice Address - Country:US
Practice Address - Phone:203-393-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT60331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice