Provider Demographics
NPI:1205249653
Name:ADISKA, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ADISKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W MAIN ST
Mailing Address - Street 2:PO BOX 519
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:49285-9483
Mailing Address - Country:US
Mailing Address - Phone:517-851-8008
Mailing Address - Fax:517-851-8836
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MI
Practice Address - Zip Code:49285-9483
Practice Address - Country:US
Practice Address - Phone:517-851-8008
Practice Address - Fax:517-851-8836
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist