Provider Demographics
NPI:1346493376
Name:MICHAEL GAGAOUDAKIS DMD PA
Entity Type:Organization
Organization Name:MICHAEL GAGAOUDAKIS DMD PA
Other - Org Name:MICHAEL GAGAOUDAKIS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAGAOUDAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-686-1576
Mailing Address - Street 1:814 A1A N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3271
Mailing Address - Country:US
Mailing Address - Phone:904-686-1576
Mailing Address - Fax:904-686-1706
Practice Address - Street 1:814 A1A N
Practice Address - Street 2:SUITE 102
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3271
Practice Address - Country:US
Practice Address - Phone:904-686-1576
Practice Address - Fax:904-686-1706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN177571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty