Healthcare Provider Details

I. General information

NPI: 1790274603
Provider Name (Legal Business Name): GREGORY GOGGANS, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 HIGHWAY 11 N STE C
CARRIERE MS
39426-7146
US

IV. Provider business mailing address

PO BOX 674474
DALLAS TX
75267-4474
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-3120
  • Fax:
Mailing address:
  • Phone: 800-864-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3983-18
License Number StateMS

VIII. Authorized Official

Name: GREGORY GOGGANS
Title or Position: OWNER
Credential: DMD
Phone: 800-864-1582