Provider Demographics
NPI:1598913170
Name:GALLUP, ASA NATHANIEL (DDS)
Entity Type:Individual
Prefix:
First Name:ASA
Middle Name:NATHANIEL
Last Name:GALLUP
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 1:218 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-3003
Mailing Address - Country:US
Mailing Address - Phone:903-872-3981
Mailing Address - Fax:
Practice Address - Street 1:218 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-3003
Practice Address - Country:US
Practice Address - Phone:903-872-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice