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General NPI Number Information
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NPI Number | 1245382068
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Entity Type | Organization
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Legal Business Name | GORDON W WOMACK DDS INC
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 3300 KEMP ROAD
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City | BEAVERCREEK
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State | OH
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Zip | 45431
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Country | US
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Telephone | 937-426-2653
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Fax | 937-426-1124
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Provider Business Mailing Address
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Address Line | 3300 KEMP ROAD
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City | BEAVERCREEK
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State | OH
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Zip | 45431
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Country | US
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Telephone | 937-426-2653
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Fax | 937-426-1124
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Authorized Official
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Title or Position | OWNER
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Name | DR. GORDON W WOMMACK
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Credential | DDS
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Telephone | 937-426-2653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 17287
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License Number State | OH
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