Provider Demographics
NPI:1659324929
Name:GILLESPIE, KEVIN ROGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROGER
Last Name:GILLESPIE
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 1:3698 CHAMBERS PASS
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7766
Mailing Address - Country:US
Mailing Address - Phone:210-539-3219
Mailing Address - Fax:
Practice Address - Street 1:3698 CHAMBERS PASS
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7766
Practice Address - Country:US
Practice Address - Phone:210-539-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222801223G0001X
VA04014159611223P0300X
CODEN.002020641223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice