Provider Demographics
NPI:1245382068
Name:GORDON W WOMACK DDS INC
Entity Type:Organization
Organization Name:GORDON W WOMACK DDS INC
Other - Org Name:BEAVERCREEK PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-426-2653
Mailing Address - Street 1:3300 KEMP ROAD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431
Mailing Address - Country:US
Mailing Address - Phone:937-426-2653
Mailing Address - Fax:937-426-1124
Practice Address - Street 1:3300 KEMP ROAD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-426-2653
Practice Address - Fax:937-426-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17287122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0617587Medicaid