Provider Demographics
NPI:1457567273
Name:GENTILE, MICHAEL DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:GENTILE
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 1:49 LAKE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4501
Mailing Address - Country:US
Mailing Address - Phone:203-869-2090
Mailing Address - Fax:203-869-2535
Practice Address - Street 1:49 LAKE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4501
Practice Address - Country:US
Practice Address - Phone:203-869-2090
Practice Address - Fax:203-869-2535
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0085651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008565OtherDENTAL LICENSE