Provider Demographics
NPI:1265728612
Name:GERALD, MARK PHILLIP (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILLIP
Last Name:GERALD
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 1:3277 S CRATER RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9285
Mailing Address - Country:US
Mailing Address - Phone:804-732-5776
Mailing Address - Fax:804-732-5782
Practice Address - Street 1:3277 S CRATER RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9285
Practice Address - Country:US
Practice Address - Phone:804-732-5776
Practice Address - Fax:804-732-5782
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014132391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice