Provider Demographics
NPI:1366870990
Name:DISMUKE, GABRIELLE AMANDA (MT)
Entity type:Individual
Prefix:MS
First Name:GABRIELLE
Middle Name:AMANDA
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3739 RIVARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4740
Mailing Address - Country:US
Mailing Address - Phone:248-785-7617
Mailing Address - Fax:
Practice Address - Street 1:7700 2ND AVE STE 410
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2411
Practice Address - Country:US
Practice Address - Phone:313-986-1100
Practice Address - Fax:313-338-3082
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor