Provider Demographics
NPI:1942409438
Name:GISH, LAURIE DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:DALE
Last Name:GISH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SEXTON DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-5133
Mailing Address - Country:US
Mailing Address - Phone:516-802-4667
Mailing Address - Fax:
Practice Address - Street 1:1025 NORTHERN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1506
Practice Address - Country:US
Practice Address - Phone:516-802-4667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0535481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice