Healthcare Provider Details

I. General information

NPI: 1477227353
Provider Name (Legal Business Name): GINO MICHAEL AN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRIT AVE
FORT BRAGG NC
28310-5582
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
FORT BRAGG NC
28310
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax:
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10679
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: