Basic Information
| Provider Information | |||||||||
| NPI: | 1265519714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENT | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W BROWN ST | ||||||||
| Address2: | |||||||||
| City: | WAUPUN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539631702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268332 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 84878 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 43303300 | 05 | WI | MEDICAID |