Provider Demographics
NPI:1174674360
Name:HERBECK, GARY EMANUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EMANUEL
Last Name:HERBECK
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 1:1355 N COURTENAY PKWY
Mailing Address - Street 2:SUITE K TOWN SQUARE
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4401
Mailing Address - Country:US
Mailing Address - Phone:321-459-0009
Mailing Address - Fax:321-459-1181
Practice Address - Street 1:1355 N COURTENAY PKWY
Practice Address - Street 2:SUITE K TOWN SQUARE
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4401
Practice Address - Country:US
Practice Address - Phone:321-459-0009
Practice Address - Fax:321-459-1181
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL081841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice