Provider Demographics
NPI:1265482350
Name:WOOLLARD, GORDON WILSON (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:WILSON
Last Name:WOOLLARD
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 MUDRY CT
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3448
Mailing Address - Country:US
Mailing Address - Phone:337-531-4833
Mailing Address - Fax:
Practice Address - Street 1:1840 BELLRICHARD
Practice Address - Street 2:CHESSER DENTAL CLINIC
Practice Address - City:FT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-4854
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics