Provider Demographics
NPI:1760779672
Name:GBELIA, DWAYNE DOUGLAS (SA-C)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:DOUGLAS
Last Name:GBELIA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 S HIGLEY RD
Mailing Address - Street 2:SUITE 114-171
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-5436
Mailing Address - Country:US
Mailing Address - Phone:480-620-4498
Mailing Address - Fax:888-411-9856
Practice Address - Street 1:3317 S HIGLEY RD
Practice Address - Street 2:SUITE 114-171
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-5436
Practice Address - Country:US
Practice Address - Phone:480-620-4498
Practice Address - Fax:888-411-9856
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09-137246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant