Healthcare Provider Details

I. General information

NPI: 1548620453
Provider Name (Legal Business Name): GAURAV JAIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6571 LUMBERJACK GUY RD MARSHFIELD CLINIC DENTAL CENTER
BLACK RIVER FALLS WI
54615-5405
US

IV. Provider business mailing address

1307 N SAINT JOSEPH AVE
MARSHFIELD WI
54449-1340
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 715-898-6208
  • Fax: 715-221-5688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1001303-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: