Basic Information
| Provider Information | |||||||||
| NPI: | 1013521400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID A GORE DDS PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CERVEN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 405 S GRANITE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANITE FALLS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982528474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606917793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 S GRANITE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANITE FALLS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982528474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187665312 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2020 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187665312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.