Provider Demographics
NPI:1104378934
Name:GOSSETT, MALCOLM AARON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:AARON
Last Name:GOSSETT
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 1:303 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6129
Mailing Address - Country:US
Mailing Address - Phone:404-551-8011
Mailing Address - Fax:
Practice Address - Street 1:2484 BRIARCLIFF RD NE STE 29
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3011
Practice Address - Country:US
Practice Address - Phone:404-315-7385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015308122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist