Provider Demographics
NPI:1790897403
Name:BROWN, GARY KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:KENNETH
Last Name:BROWN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 CHESTER BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1919
Mailing Address - Country:US
Mailing Address - Phone:765-962-6734
Mailing Address - Fax:765-939-0237
Practice Address - Street 1:1471 CHESTER BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1919
Practice Address - Country:US
Practice Address - Phone:765-962-6734
Practice Address - Fax:765-939-0237
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007218A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice