Healthcare Provider Details

I. General information

NPI: 1548284631
Provider Name (Legal Business Name): GARY M EASLEY, DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 VALLEY FORGE ST
COMANCHE TX
76442
US

IV. Provider business mailing address

PO BOX 705 203 VALLEY FORGE ST
COMANCHE TX
76442-0705
US

V. Phone/Fax

Practice location:
  • Phone: 325-356-5263
  • Fax: 325-356-2875
Mailing address:
  • Phone: 325-356-5263
  • Fax: 325-356-2875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11309
License Number StateTX

VIII. Authorized Official

Name: DR. GARY M EASLEY
Title or Position: PRESIDENT
Credential: DDS
Phone: 325-356-5263