Provider Demographics
NPI:1174611388
Name:SILVA, GARY J (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:SILVA
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 1:1205 W VINE ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5109
Mailing Address - Country:US
Mailing Address - Phone:209-369-0294
Mailing Address - Fax:209-369-0297
Practice Address - Street 1:1205 W VINE ST
Practice Address - Street 2:SUITE 18
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5109
Practice Address - Country:US
Practice Address - Phone:209-369-0294
Practice Address - Fax:209-369-0297
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist