Provider Demographics
NPI:1992862197
Name:GANZ, JOSEPH RAYMOND (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RAYMOND
Last Name:GANZ
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 1:917 LESLIE BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3588
Mailing Address - Country:US
Mailing Address - Phone:573-634-2400
Mailing Address - Fax:573-761-7528
Practice Address - Street 1:917 LESLIE BLVD
Practice Address - Street 2:STE C
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-3588
Practice Address - Country:US
Practice Address - Phone:573-634-2400
Practice Address - Fax:573-761-7528
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist