Healthcare Provider Details

I. General information

NPI: 1710819354
Provider Name (Legal Business Name): MICHAEL GNEZDA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 ANDREW AVE
LA PORTE IN
46350-5339
US

IV. Provider business mailing address

805 WELLINGTON DR
DYER IN
46311-1253
US

V. Phone/Fax

Practice location:
  • Phone: 708-752-6591
  • Fax:
Mailing address:
  • Phone: 708-752-6591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12015014A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: