Provider Demographics
NPI:1578237608
Name:GRG DENTAL, PLLC
Entity Type:Organization
Organization Name:GRG DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-897-3406
Mailing Address - Street 1:1414 E MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4817
Mailing Address - Country:US
Mailing Address - Phone:407-897-3406
Mailing Address - Fax:407-895-8275
Practice Address - Street 1:1414 E MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4817
Practice Address - Country:US
Practice Address - Phone:407-897-3406
Practice Address - Fax:407-895-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty