Provider Demographics
NPI:1316935448
Name:CIRCOSTA, GARY FRANK (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:FRANK
Last Name:CIRCOSTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1751
Mailing Address - Country:US
Mailing Address - Phone:508-886-6451
Mailing Address - Fax:508-886-0167
Practice Address - Street 1:93 VAN DEENE AVE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3236
Practice Address - Country:US
Practice Address - Phone:413-734-9400
Practice Address - Fax:413-734-9408
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA119381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0209821Medicaid