Provider Demographics
NPI:1922585694
Name:GORDON W. WOMACK DDS INC
Entity Type:Organization
Organization Name:GORDON W. WOMACK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIAILST
Authorized Official - Prefix:
Authorized Official - First Name:TAMONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-244-4844
Mailing Address - Street 1:3300 KEMP RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-4200
Mailing Address - Country:US
Mailing Address - Phone:937-426-2653
Mailing Address - Fax:
Practice Address - Street 1:3300 KEMP RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-426-2653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty