Provider Demographics
NPI:1639186182
Name:MYERS, GARY R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:MYERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3200 OLD JENNINGS ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3414
Mailing Address - Country:US
Mailing Address - Phone:904-505-2010
Mailing Address - Fax:904-505-2011
Practice Address - Street 1:3200 OLD JENNINGS ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3414
Practice Address - Country:US
Practice Address - Phone:904-505-2010
Practice Address - Fax:904-505-2011
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN149031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1768502OtherUNITED CONCORDIA
85410OtherBLUE CROSS BLUE SHIELD