Provider Demographics
NPI:1568432870
Name:SELDOMRIDGE, GARY WARNER (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WARNER
Last Name:SELDOMRIDGE
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 1:190 GOOD DR.
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603
Mailing Address - Country:US
Mailing Address - Phone:717-394-3033
Mailing Address - Fax:717-390-2641
Practice Address - Street 1:190 GOOD DR.
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603
Practice Address - Country:US
Practice Address - Phone:717-394-3033
Practice Address - Fax:717-390-2641
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026049L1223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA32271OtherBLUE SHIELD
PADS026049LOtherDENTAL LICENSE
PA1730915Medicaid
PADS026049LOtherDENTAL LICENSE
PA187755EBFMedicare ID - Type Unspecified