Basic Information
Provider Information | |||||||||
NPI: | 1659324929 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILLESPIE | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | ROGER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 577 STERNBERG AVE | ||||||||
Address2: |   | ||||||||
City: | FORT EUSTIS | ||||||||
State: | VA | ||||||||
PostalCode: | 236041526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753147944 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1811 ARMY BLVD | ||||||||
Address2: |   | ||||||||
City: | JBSA FT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782342686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102210826 | ||||||||
FaxNumber: | 2102210824 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 04/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22280 | TX | N |   | Dental Providers | Dentist | General Practice | 1223P0300X | 0401415961 | VA | Y |   | Dental Providers | Dentist | Periodontics |
No ID Information.