Provider Demographics
NPI:1154595379
Name:GAST, GARRETT DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:DAVID
Last Name:GAST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8700 DIXIE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258
Mailing Address - Country:US
Mailing Address - Phone:502-935-0505
Mailing Address - Fax:502-935-2602
Practice Address - Street 1:3435 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3217
Practice Address - Country:US
Practice Address - Phone:773-588-8200
Practice Address - Fax:773-588-8208
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56258122300000X
IL019028623122300000X
KY9844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist