MEDICARE: DR. GARY G. GOLASA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12490	MI

General Provider Information

NPI Number	:	1548444920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY G. GOLASA D.D.S.

Provider Business Mailing Address
First Line	:	3058 METRO PKWY STE 109
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-3600
Country	:	US
Telephone Number	:	586-979-7140
Fax Number	:

Provider Business Practice Location Address
First Line	:	3058 METRO PKWY STE 109
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-3600
Country	:	US
Telephone Number	:	586-979-7140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	12/20/2007

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