Provider Demographics
NPI:1851405732
Name:GULLIKSON, GREGORY LEE (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:GULLIKSON
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 1:1853 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5492
Mailing Address - Country:US
Mailing Address - Phone:321-267-2934
Mailing Address - Fax:321-267-3698
Practice Address - Street 1:1853 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5492
Practice Address - Country:US
Practice Address - Phone:321-267-2934
Practice Address - Fax:321-267-3698
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00119871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL63699OtherBCBS PROVIDER NUMBER