Provider Demographics
NPI:1396782447
Name:GISTARO, NICHOLAS MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:GISTARO
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 1:549 H ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4302
Mailing Address - Country:US
Mailing Address - Phone:619-426-6891
Mailing Address - Fax:619-426-0913
Practice Address - Street 1:549 H ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4302
Practice Address - Country:US
Practice Address - Phone:619-426-6891
Practice Address - Fax:619-426-0913
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0292821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice