Provider Demographics
NPI:1770654832
Name:WELLER, GARY P (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
Last Name:WELLER
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:825 MAJESTIC CT
Mailing Address - Street 2:STE. C
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5186
Mailing Address - Country:US
Mailing Address - Phone:704-864-6721
Mailing Address - Fax:704-864-1175
Practice Address - Street 1:825 MAJESTIC CT
Practice Address - Street 2:STE. C
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5186
Practice Address - Country:US
Practice Address - Phone:704-864-6721
Practice Address - Fax:704-864-1175
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC44171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8999096Medicaid