Provider Demographics
NPI:1174398416
Name:GUSSOW DENTAL CARE PROF CORP
Entity type:Organization
Organization Name:GUSSOW DENTAL CARE PROF CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-371-0221
Mailing Address - Street 1:10420 S DECATUR BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-8718
Mailing Address - Country:US
Mailing Address - Phone:702-371-0221
Mailing Address - Fax:
Practice Address - Street 1:4343 N RANCHO DR STE 131
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3422
Practice Address - Country:US
Practice Address - Phone:702-395-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty