Provider Demographics
NPI:1932387719
Name:GASTON FAMILY HEALTH SERVICES
Entity Type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES
Other - Org Name:OPEN DOOR DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-874-3313
Mailing Address - Street 1:991 WEST HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052
Mailing Address - Country:US
Mailing Address - Phone:704-853-5191
Mailing Address - Fax:704-853-5131
Practice Address - Street 1:991 WEST HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052
Practice Address - Country:US
Practice Address - Phone:704-853-5191
Practice Address - Fax:704-853-5131
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-05
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC341927Medicare Oscar/Certification