Provider Demographics
NPI:1912004359
Name:CHIKE, GARY EUGENE (DMD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EUGENE
Last Name:CHIKE
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 1:506 HWY 80 W
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2104
Mailing Address - Country:US
Mailing Address - Phone:912-656-8728
Mailing Address - Fax:
Practice Address - Street 1:506 HWY 80 W
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2104
Practice Address - Country:US
Practice Address - Phone:912-656-8728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123631223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000937428EMedicaid