Healthcare Provider Details

I. General information

NPI: 1578237608
Provider Name (Legal Business Name): GRG DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 E MICHIGAN ST
ORLANDO FL
32806-4817
US

IV. Provider business mailing address

1414 E MICHIGAN ST
ORLANDO FL
32806-4817
US

V. Phone/Fax

Practice location:
  • Phone: 407-897-3406
  • Fax: 407-895-8275
Mailing address:
  • Phone: 407-897-3406
  • Fax: 407-895-8275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY R GIBSON
Title or Position: OWNER
Credential: DMD
Phone: 407-897-3406