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General NPI Number Information
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NPI Number | 1114136926
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Entity Type | Individual
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Provider Name | GAVIN MALCOLM AARON DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3005 PETERS CREEK RD NW
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City | ROANOKE
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State | VA
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Zip | 24019-2738
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Country | US
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Telephone | 540-562-3166
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Fax | 540-562-0760
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Provider Business Mailing Address
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Address Line | 3005 PETERS CREEK RD NW
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City | ROANOKE
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State | VA
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Zip | 24019-2738
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Country | US
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Telephone | 540-562-3166
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Fax | 540-562-0760
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 0401410685
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License Number State | VA
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