Provider Demographics
NPI:1821580424
Name:GOUSMAN, JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:GOUSMAN
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 1:337 S LEANDRO
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2655
Mailing Address - Country:US
Mailing Address - Phone:757-268-2066
Mailing Address - Fax:
Practice Address - Street 1:1929 E RAY RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-8722
Practice Address - Country:US
Practice Address - Phone:480-498-8825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist