Provider Demographics
NPI:1700930708
Name:J. CHRIS GORHAM PA
Entity Type:Organization
Organization Name:J. CHRIS GORHAM PA
Other - Org Name:ROUND ROCK FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J. CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-255-7839
Mailing Address - Street 1:2000 S I H 35 STE K1
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-6916
Mailing Address - Country:US
Mailing Address - Phone:512-255-7839
Mailing Address - Fax:512-255-7898
Practice Address - Street 1:2000 S I H 35 STE K1
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-6916
Practice Address - Country:US
Practice Address - Phone:512-255-7839
Practice Address - Fax:512-255-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89D255OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX89D254OtherBLUE CROSS BLUE SHIELD OF TEXAS