Healthcare Provider Details

I. General information

NPI: 1770565939
Provider Name (Legal Business Name): GASTON EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 LOWER DALLAS HWY
DALLAS NC
28034-9368
US

IV. Provider business mailing address

820 LOWER DALLAS HWY
DALLAS NC
28034-9368
US

V. Phone/Fax

Practice location:
  • Phone: 704-922-9808
  • Fax: 704-922-8213
Mailing address:
  • Phone: 704-922-9808
  • Fax: 704-922-8213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1826
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1048
License Number StateNC

VIII. Authorized Official

Name: DR. RANDALL D HOLLAND
Title or Position: PARTNER
Credential: M.D.
Phone: 704-922-9808