Provider Demographics
NPI:1831212331
Name:WISCOVITCH, GUSTAVO J (DMD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:J
Last Name:WISCOVITCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6031 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-1139
Mailing Address - Country:US
Mailing Address - Phone:727-521-6645
Mailing Address - Fax:727-521-6648
Practice Address - Street 1:6031 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-1139
Practice Address - Country:US
Practice Address - Phone:727-521-6645
Practice Address - Fax:727-521-6648
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00144991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics