Provider Demographics
NPI:1962046268
Name:COUCH, GIANCARLO (DDS)
Entity type:Individual
Prefix:DR
First Name:GIANCARLO
Middle Name:
Last Name:COUCH
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 1:1340 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4807
Mailing Address - Country:US
Mailing Address - Phone:929-229-6445
Mailing Address - Fax:
Practice Address - Street 1:777 E PARK AVE
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3508
Practice Address - Country:US
Practice Address - Phone:715-723-0366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001102122300000X
MO20190372981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice