Provider Demographics
NPI:1336257765
Name:GENTRY, CHRISTIAN B (SA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:B
Last Name:GENTRY
Suffix:
Gender:M
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 OLD ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3648
Mailing Address - Country:US
Mailing Address - Phone:248-681-5207
Mailing Address - Fax:
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-5813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2423363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical