Healthcare Provider Details

I. General information

NPI: 1578523619
Provider Name (Legal Business Name): GARY M JUDIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 CLYDE MOORE DR
GROVEPORT OH
43125-2009
US

IV. Provider business mailing address

5940 CLYDE MOORE DR
GROVEPORT OH
43125-2010
US

V. Phone/Fax

Practice location:
  • Phone: 614-492-1471
  • Fax: 614-492-1480
Mailing address:
  • Phone: 614-492-1471
  • Fax: 614-492-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19680
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: