Healthcare Provider Details

I. General information

NPI: 1750553517
Provider Name (Legal Business Name): RONALD D. GAITROS, DDS, MS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 MEDICAL CENTER DR
WILMINGTON NC
28401-7305
US

IV. Provider business mailing address

1122 MEDICAL CENTER DR
WILMINGTON NC
28401-7305
US

V. Phone/Fax

Practice location:
  • Phone: 910-762-2618
  • Fax: 910-763-5173
Mailing address:
  • Phone: 910-762-2618
  • Fax: 910-763-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5707
License Number StateND

VIII. Authorized Official

Name: MR. RONALD D. GAITROS
Title or Position: OFFICER/DIRECTOR
Credential: DDS, MS
Phone: 910-762-2618