Provider Demographics
NPI:1558733410
Name:GASTONIA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GASTONIA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-710-8011
Mailing Address - Street 1:2557 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4712
Mailing Address - Country:US
Mailing Address - Phone:704-854-8887
Mailing Address - Fax:
Practice Address - Street 1:2557 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4712
Practice Address - Country:US
Practice Address - Phone:704-854-8887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8726122300000X
NC9309122300000X
NC9534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty