Provider Demographics
NPI:1487776712
Name:KODISH, GARY S (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:KODISH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2505
Mailing Address - Country:US
Mailing Address - Phone:954-462-5252
Mailing Address - Fax:954-462-5145
Practice Address - Street 1:301 SE 16TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2505
Practice Address - Country:US
Practice Address - Phone:954-462-5252
Practice Address - Fax:954-462-5145
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL82051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592018927OtherFED TAX ID