Provider Demographics
NPI:1386894384
Name:GALLANT, GERALDINE OCAMPO (DD,S,)
Entity type:Individual
Prefix:DR
First Name:GERALDINE
Middle Name:OCAMPO
Last Name:GALLANT
Suffix:
Gender:F
Credentials:DD,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1829
Mailing Address - Country:US
Mailing Address - Phone:313-882-6870
Mailing Address - Fax:
Practice Address - Street 1:1448 SOUTHBOUND GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-6533
Practice Address - Country:US
Practice Address - Phone:586-954-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010168181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice