Provider Demographics
NPI:1548356702
Name:DERDERIAN, GAY M (DDS)
Entity type:Individual
Prefix:DR
First Name:GAY
Middle Name:M
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1881
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1881
Mailing Address - Country:US
Mailing Address - Phone:414-288-0788
Mailing Address - Fax:414-288-0678
Practice Address - Street 1:1801 WEST WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-288-0788
Practice Address - Fax:414-288-0678
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33700151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics