Basic Information
| Provider Information | |||||||||
| NPI: | 1194150946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAZAROV | ||||||||
| FirstName: | SERGEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38717 38TH STREET | ||||||||
| Address2: | USA DENTAC | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 351 W 6TH STREET, BLDG 440 | ||||||||
| Address2: | USA DENTAL HEALTH ACTIVITY | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124356249 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2013 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 62674 | CA | N | Dental Providers | Dentist | 1223S0112X | 9549 | SC | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.