MEDICARE: DR. VIRDISLAND CHARLES GAMBLE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22934	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174855589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRDISLAND CHARLES GAMBLE DDS

Provider Business Mailing Address
First Line	:	7120 FM 1464 RD
Second Line	:	SUITE B
City	:	RICHMOND
State	:	TX
Zip	:	77407-6400
Country	:	US
Telephone Number	:	713-340-1300
Fax Number	:	281-271-8617

Provider Business Practice Location Address
First Line	:	7120 FM 1464 RD
Second Line	:	SUITEB
City	:	RICHMOND
State	:	TX
Zip	:	77407-6400
Country	:	US
Telephone Number	:	713-340-1300
Fax Number	:	281-271-8617

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2010
Last Update Date	:	08/20/2012

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