Provider Demographics
NPI:1023245842
Name:GADY, JACOB MARSHALL (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARSHALL
Last Name:GADY
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2408
Mailing Address - Country:US
Mailing Address - Phone:860-231-1030
Mailing Address - Fax:860-231-1032
Practice Address - Street 1:80 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2408
Practice Address - Country:US
Practice Address - Phone:860-231-1030
Practice Address - Fax:860-231-1032
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT011331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist