1225053283 NPI number — DR. GENE GORDON GRESS DDS

Table of content: DR. GENE GORDON GRESS DDS (NPI 1225053283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225053283 NPI number — DR. GENE GORDON GRESS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRESS
Provider First Name:
GENE
Provider Middle Name:
GORDON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225053283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9801 ANDERSON MILL RD
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78750-2274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-258-0670
Provider Business Mailing Address Fax Number:
512-258-0672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9801 ANDERSON MILL RD
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78750-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-258-0670
Provider Business Practice Location Address Fax Number:
512-258-0672
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 13087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 090924404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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