Provider Demographics
NPI:1467412346
Name:FIELDEN, GARY L (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:FIELDEN
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 1:1205 N WILCOX DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4922
Mailing Address - Country:US
Mailing Address - Phone:423-247-5127
Mailing Address - Fax:
Practice Address - Street 1:1205 N WILCOX DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4922
Practice Address - Country:US
Practice Address - Phone:423-247-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS28721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178637Medicaid
TNQ007318Medicaid