Healthcare Provider Details

I. General information

NPI: 1679781660
Provider Name (Legal Business Name): SAMUEL GELSO JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4480 ACUSHNET AVE
NEW BEDFORD MA
02745-4709
US

IV. Provider business mailing address

4480 ACUSHNET AVE
NEW BEDFORD MA
02745-4709
US

V. Phone/Fax

Practice location:
  • Phone: 508-995-8008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17866MA
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: