Healthcare Provider Details

I. General information

NPI: 1144291311
Provider Name (Legal Business Name): KENT GORE
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MCHUGH BLVD 2D DENTAL BATTALION/ NAVAL DENTAL CENTER
CAMP LEJEUNE NC
28547-2511
US

IV. Provider business mailing address

5203 WEBB CT
MOREHEAD CITY NC
28557-2569
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-2208
  • Fax: 910-451-8036
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0401005780
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5810
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: