Provider Demographics
NPI:1659801629
Name:GASS, CODY ALLEN (DMD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:ALLEN
Last Name:GASS
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 1:8918 N COUNTY ROAD 000E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-6504
Mailing Address - Country:US
Mailing Address - Phone:217-962-1327
Mailing Address - Fax:
Practice Address - Street 1:601 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4340
Practice Address - Country:US
Practice Address - Phone:217-235-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist