Provider Demographics
NPI:1982085296
Name:GREGORY L GULLIKSON DMD PA
Entity Type:Organization
Organization Name:GREGORY L GULLIKSON DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GULLIKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-267-2934
Mailing Address - Street 1:1853 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5492
Mailing Address - Country:US
Mailing Address - Phone:321-267-2934
Mailing Address - Fax:321-267-3698
Practice Address - Street 1:1853 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5492
Practice Address - Country:US
Practice Address - Phone:321-267-2934
Practice Address - Fax:321-267-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty