Healthcare Provider Details

I. General information

NPI: 1376544205
Provider Name (Legal Business Name): GWEN GIANNINA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date: 03/21/2006
Reactivation Date: 04/02/2013

III. Provider practice location address

1173 KENNEDY BLVD
BAYONNE NJ
07002-3132
US

IV. Provider business mailing address

1173 KENNEDY BLVD
BAYONNE NJ
07002
US

V. Phone/Fax

Practice location:
  • Phone: 201-339-1177
  • Fax: 201-339-2120
Mailing address:
  • Phone: 201-339-1177
  • Fax: 201-339-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number057765
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20518
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02051800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: