Provider Demographics
NPI:1679675292
Name:GAINES, ROY E JR (DDS, MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:E
Last Name:GAINES
Suffix:JR
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 002
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7512
Mailing Address - Country:US
Mailing Address - Phone:919-787-3949
Mailing Address - Fax:919-787-7634
Practice Address - Street 1:4201 LAKE BOONE TRL
Practice Address - Street 2:SUITE 002
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7512
Practice Address - Country:US
Practice Address - Phone:919-787-3949
Practice Address - Fax:919-787-7634
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8993014Medicaid
NC8993014Medicaid
NCF80034Medicare UPIN