Provider Demographics
NPI:1295072973
Name:GIZACHEW, ADMASU N
Entity type:Individual
Prefix:DR
First Name:ADMASU
Middle Name:N
Last Name:GIZACHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 CENTER BLVD
Mailing Address - Street 2:SUITE 1902
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5619
Mailing Address - Country:US
Mailing Address - Phone:231-580-9205
Mailing Address - Fax:888-557-2030
Practice Address - Street 1:1683 ROUTE 88 STE C
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3072
Practice Address - Country:US
Practice Address - Phone:347-455-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02524100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist