Healthcare Provider Details

I. General information

NPI: 1568523538
Provider Name (Legal Business Name): RICHARD L GAINES DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MADISON AVE
LAKEWOOD NJ
08701-3266
US

IV. Provider business mailing address

301 MADISON AVE
LAKEWOOD NJ
08701-3266
US

V. Phone/Fax

Practice location:
  • Phone: 732-367-4042
  • Fax: 732-905-9210
Mailing address:
  • Phone: 732-367-4042
  • Fax: 732-905-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI00910300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: