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General NPI Number Information
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NPI Number | 1982085296
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Entity Type | Organization
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Legal Business Name | GREGORY L GULLIKSON DMD PA
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Dates
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Enumeration Date | 06/11/2015
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Last Update Date | 06/11/2015
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Provider Practice Location Address
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Address Line | 1853 KNOX MCRAE DR
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City | TITUSVILLE
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State | FL
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Zip | 32780-5492
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Country | US
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Telephone | 321-267-2934
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Fax | 321-267-3698
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Provider Business Mailing Address
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Address Line | 1853 KNOX MCRAE DR
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City | TITUSVILLE
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State | FL
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Zip | 32780-5492
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Country | US
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Telephone | 321-267-2934
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Fax | 321-267-3698
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Authorized Official
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Title or Position | DENTIST
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Name | GREGORY LEE GULLIKSON
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Credential | DMD
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Telephone | 321-267-2934
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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 | DN11987
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License Number State | FL
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