Healthcare Provider Details

I. General information

NPI: 1205997301
Provider Name (Legal Business Name): GERALD LAWRENCE MUNCY SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MORENCI SHOPPING CENTER SUITE11
MORENCI AZ
85540
US

IV. Provider business mailing address

PO BOX 99 MORENCI SHOPPING PLAZA SUITE 11
MORENCI AZ
85540-0099
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-2332
  • Fax: 928-865-1218
Mailing address:
  • Phone: 928-865-2332
  • Fax: 928-865-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1177
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: