Healthcare Provider Details

I. General information

NPI: 1891203055
Provider Name (Legal Business Name): GATEWAY DENTAL COLUMBUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2459 W JONATHAN MOORE PIKE
COLUMBUS IN
47201-9206
US

IV. Provider business mailing address

2459 W JONATHAN MOORE PIKE
COLUMBUS IN
47201-9206
US

V. Phone/Fax

Practice location:
  • Phone: 812-669-0123
  • Fax:
Mailing address:
  • Phone: 812-669-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12010768A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. AARON WAYNE STRICKLAND
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 812-669-0123