Provider Demographics
NPI:1669173332
Name:GARGANO, MARCO ANTONIO (DDS)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
Last Name:GARGANO
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 1:1017 SHORE ACRES LOOP
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-2975
Mailing Address - Country:US
Mailing Address - Phone:501-701-0908
Mailing Address - Fax:
Practice Address - Street 1:2910 TRIMBLE RD STE 109
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7126
Practice Address - Country:US
Practice Address - Phone:573-303-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20230195471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program