Healthcare Provider Details

I. General information

NPI: 1538277215
Provider Name (Legal Business Name): GARY ADISKA D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
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 P.O. 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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14371
License Number StateMI

VIII. Authorized Official

Name: MRS. CARRIE KRACHIE
Title or Position: BUSINESS STAFF
Credential:
Phone: 517-851-8008