Provider Demographics
NPI:1013920669
Name:RASKA, GARY MARTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARTIN
Last Name:RASKA
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 1:3940 SWIFT RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-6541
Mailing Address - Country:US
Mailing Address - Phone:941-923-0033
Mailing Address - Fax:941-922-4621
Practice Address - Street 1:3940 SWIFT RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-6541
Practice Address - Country:US
Practice Address - Phone:941-923-0033
Practice Address - Fax:941-922-4621
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083881223S0112X
FLDN185831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0493114Medicaid
MO000169002OtherPTAN