Provider Demographics
NPI:1386041549
Name:GAVIN TROGDON DDS PA
Entity Type:Organization
Organization Name:GAVIN TROGDON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:479-267-5009
Mailing Address - Street 1:181 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-2945
Mailing Address - Country:US
Mailing Address - Phone:479-267-5009
Mailing Address - Fax:479-267-5029
Practice Address - Street 1:181 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-2945
Practice Address - Country:US
Practice Address - Phone:479-267-5009
Practice Address - Fax:479-267-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR39591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198735608Medicaid