Healthcare Provider Details

I. General information

NPI: 1710001177
Provider Name (Legal Business Name): GEZI MEBRATU DDS, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 RIDGE RD
ROCKWALL TX
75032
US

IV. Provider business mailing address

2918 RIDGE RD
ROCKWALL TX
75032
US

V. Phone/Fax

Practice location:
  • Phone: 469-769-1050
  • Fax: 469-769-1202
Mailing address:
  • Phone: 469-769-1050
  • Fax: 469-769-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number21669
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: