Provider Demographics
NPI:1184632010
Name:ZGODINSKI, GERALD DANIEL (DDS)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:DANIEL
Last Name:ZGODINSKI
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 1:6248 NORTH RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2567
Mailing Address - Country:US
Mailing Address - Phone:440-428-1101
Mailing Address - Fax:440-428-6985
Practice Address - Street 1:6248 NORTH RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2567
Practice Address - Country:US
Practice Address - Phone:440-428-1101
Practice Address - Fax:440-428-6985
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30018002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0753788Medicaid