Provider Demographics
NPI:1184648420
Name:SEGRAVES, GERALD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:SEGRAVES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15382 SAINT CHARLES ST # A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3122
Mailing Address - Country:US
Mailing Address - Phone:228-832-5300
Mailing Address - Fax:228-832-7626
Practice Address - Street 1:15382 SAINT CHARLES ST # A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3122
Practice Address - Country:US
Practice Address - Phone:228-832-5300
Practice Address - Fax:228-832-7626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1616-741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice