Provider Demographics
NPI:1356435077
Name:DEMKO, B GAIL (DMD,)
Entity type:Individual
Prefix:DR
First Name:B
Middle Name:GAIL
Last Name:DEMKO
Suffix:
Gender:F
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:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-0004
Mailing Address - Country:US
Mailing Address - Phone:617-964-4028
Mailing Address - Fax:617-595-4591
Practice Address - Street 1:140 MERRIAM ST
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1319
Practice Address - Country:US
Practice Address - Phone:617-964-4028
Practice Address - Fax:617-595-4591
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141131223D0001X
MI12010332A1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6491640001OtherPTAN
MADEX30006Medicare ID - Type Unspecified
MAT57245Medicare UPIN
T57245Medicare UPIN