Healthcare Provider Details

I. General information

NPI: 1245482629
Provider Name (Legal Business Name): GEORGE SHELTON GAYLE IV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 YORKTOWN ST #880
HOUSTON TX
77056-4182
US

IV. Provider business mailing address

1776 YORKTOWN ST #880
HOUSTON TX
77056-4182
US

V. Phone/Fax

Practice location:
  • Phone: 713-627-1090
  • Fax:
Mailing address:
  • Phone: 713-627-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22108
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: