Provider Demographics
NPI:1558611087
Name:PEVOW, GERALD BERNARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:BERNARD
Last Name:PEVOW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 W ANDERSON LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1338
Mailing Address - Country:US
Mailing Address - Phone:512-459-4347
Mailing Address - Fax:512-459-4348
Practice Address - Street 1:1802 W ANDERSON LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1338
Practice Address - Country:US
Practice Address - Phone:512-459-4347
Practice Address - Fax:512-459-4348
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28628122300000X
TX282681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist