Provider Demographics
NPI:1881768166
Name:MINICLIER, GORDON JOSEPH (DDS PC)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:JOSEPH
Last Name:MINICLIER
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:150 WEST MAIN STREET
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-0560
Mailing Address - Country:US
Mailing Address - Phone:276-773-3521
Mailing Address - Fax:276-773-3822
Practice Address - Street 1:150 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-0560
Practice Address - Country:US
Practice Address - Phone:276-773-3521
Practice Address - Fax:276-773-3822
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice