Healthcare Provider Details

I. General information

NPI: 1821008301
Provider Name (Legal Business Name): CHARLES ARTHUR GILMORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 W NOB HILL BLVD
YAKIMA WA
98908-3900
US

IV. Provider business mailing address

4114 W NOB HILL BLVD
YAKIMA WA
98908-3900
US

V. Phone/Fax

Practice location:
  • Phone: 509-965-4114
  • Fax:
Mailing address:
  • Phone: 509-965-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00005571
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: