Healthcare Provider Details

I. General information

NPI: 1861761132
Provider Name (Legal Business Name): GEORGE GRAY FLYNN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2468 BLANDING BLVD SUITE 103
MIDDLEBURG FL
32068-5193
US

IV. Provider business mailing address

2468 BLANDING BLVD SUITE 103
MIDDLEBURG FL
32068-5193
US

V. Phone/Fax

Practice location:
  • Phone: 904-282-5025
  • Fax:
Mailing address:
  • Phone: 904-282-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8514
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: