Provider Demographics
NPI:1932288487
Name:COHEN, GARY A (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:COHEN
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 1:27560 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-3156
Mailing Address - Country:US
Mailing Address - Phone:734-422-5480
Mailing Address - Fax:734-422-3446
Practice Address - Street 1:27560 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-3156
Practice Address - Country:US
Practice Address - Phone:734-422-5480
Practice Address - Fax:734-422-3446
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI151021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15102OtherSTATE LICENSE NUMBER
MI718876OtherUNITED CONCORDIA