Provider Demographics
NPI:1962725077
Name:GUSTER LOSEY & MACK DDS INC
Entity type:Organization
Organization Name:GUSTER LOSEY & MACK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:REYNOLDS
Authorized Official - Last Name:LOSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-642-8500
Mailing Address - Street 1:1055 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8668
Mailing Address - Country:US
Mailing Address - Phone:937-642-8500
Mailing Address - Fax:937-642-5474
Practice Address - Street 1:1055 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8668
Practice Address - Country:US
Practice Address - Phone:937-642-8500
Practice Address - Fax:937-642-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0222151223G0001X
OH300212731223G0001X
OH300234501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2332685Medicaid
OH3158130Medicaid
OH2663336Medicaid