Provider Demographics
NPI:1336262708
Name:CLUSSERATH, GARY P (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
Last Name:CLUSSERATH
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 1:7904 ZENITH DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-1075
Mailing Address - Country:US
Mailing Address - Phone:530-426-3711
Mailing Address - Fax:530-426-3711
Practice Address - Street 1:7904 ZENITH DR
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1075
Practice Address - Country:US
Practice Address - Phone:530-426-3711
Practice Address - Fax:530-426-3711
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA456681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice