Provider Demographics
NPI:1780036772
Name:GILLEY, DREW
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:GILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 N 190 E
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2573
Mailing Address - Country:US
Mailing Address - Phone:801-707-7825
Mailing Address - Fax:
Practice Address - Street 1:375 E LAGOON ST,
Practice Address - Street 2:ROOSEVELT, UT 84066
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9816603-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist