Healthcare Provider Details

I. General information

NPI: 1538136106
Provider Name (Legal Business Name): DAVID J GINGRASS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 NORTH MAYFAIR RD SUITE 102
MILWAUKEE WI
53226-1506
US

IV. Provider business mailing address

2323 NORTH MAYFAIR RD SUITE 102
MILWAUKEE WI
53226-1506
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-1161
  • Fax: 414-257-0194
Mailing address:
  • Phone: 414-257-1161
  • Fax: 414-257-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS001616015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: