Provider Demographics
NPI:1942298443
Name:GAITROS, RONALD DALE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DALE
Last Name:GAITROS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7305
Mailing Address - Country:US
Mailing Address - Phone:910-762-2618
Mailing Address - Fax:910-763-5173
Practice Address - Street 1:1122 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7305
Practice Address - Country:US
Practice Address - Phone:910-762-2618
Practice Address - Fax:910-763-5173
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC57071223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC93034OtherBLUE CROSS BLUE SHIELD #
NC8993034Medicaid
NC93034OtherBLUE CROSS BLUE SHIELD #
NCU25927Medicare UPIN