Provider Demographics
NPI:1487702528
Name:GAMMELLO, MARK RAYMOND (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAYMOND
Last Name:GAMMELLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-1322
Mailing Address - Country:US
Mailing Address - Phone:814-437-1284
Mailing Address - Fax:814-432-3339
Practice Address - Street 1:1254 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-1322
Practice Address - Country:US
Practice Address - Phone:814-437-1284
Practice Address - Fax:814-432-3339
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025821L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice