Healthcare Provider Details

I. General information

NPI: 1205249653
Provider Name (Legal Business Name): GARY ADISKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W MAIN ST
STOCKBRIDGE MI
49285-9483
US

IV. Provider business mailing address

100 W MAIN ST PO BOX 519
STOCKBRIDGE MI
49285-9483
US

V. Phone/Fax

Practice location:
  • Phone: 517-851-8008
  • Fax: 517-851-8836
Mailing address:
  • Phone: 517-851-8008
  • Fax: 517-851-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901014371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: