Provider Demographics
NPI:1922026632
Name:GALLISDORFER, JEFFREY MELVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MELVIN
Last Name:GALLISDORFER
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 1:116 JONESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4617
Mailing Address - Country:US
Mailing Address - Phone:336-768-7495
Mailing Address - Fax:336-768-7499
Practice Address - Street 1:116 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4617
Practice Address - Country:US
Practice Address - Phone:336-768-7495
Practice Address - Fax:336-768-7499
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice