=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972190718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RONALD D GORE, DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2020
-----------------------------------------------------
Last Update Date | 12/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 MAIN ST
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72112-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-523-3669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 MAIN ST
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72112-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-523-3669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | RONALD D GORE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 870-523-3669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------