Provider Demographics
NPI:1386971968
Name:JAN WADE GILBERT DMD PC
Entity type:Organization
Organization Name:JAN WADE GILBERT DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-239-3333
Mailing Address - Street 1:176 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1731
Mailing Address - Country:US
Mailing Address - Phone:516-239-3333
Mailing Address - Fax:
Practice Address - Street 1:176 BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1731
Practice Address - Country:US
Practice Address - Phone:516-239-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0291021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty