Basic Information
| Provider Information | |||||||||
| NPI: | 1548620453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | GAURAV | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 LAKELAND DRIVE | ||||||||
| Address2: | MARSHFIELD CLINIC DENTAL CENTER | ||||||||
| City: | CHIPPEWA FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157382000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | N6571 LUMBERJACK GUY RD | ||||||||
| Address2: | MARSHFIELD CLINIC DENTAL CENTER | ||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1001303-15 | WI | Y | Dental Providers | Dentist |
No ID Information.