1235544958 NPI number — GINO A GISMONDI DDS PLLC

Table of content: (NPI 1235544958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235544958 NPI number — GINO A GISMONDI DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GINO A GISMONDI DDS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235544958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W PIKE ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CLARKSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26301-2696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-622-4828
Provider Business Mailing Address Fax Number:
304-624-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W PIKE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CLARKSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26301-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-622-4828
Provider Business Practice Location Address Fax Number:
304-624-0977
Provider Enumeration Date:
06/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VILAIN
Authorized Official First Name:
JOCELYN
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
304-622-4828

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  3781 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810026369 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3073126 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3910006064 . This is a "MEDICAID GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001750853 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810000420 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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