MEDICARE: CUSTOM DENTAL OF GAINESVILLE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1225832983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM DENTAL OF GAINESVILLE PLLC

Provider Business Mailing Address
First Line	:	301 E CALIFORNIA ST
Second Line	:
City	:	GAINESVILLE
State	:	TX
Zip	:	76240-4005
Country	:	US
Telephone Number	:	940-665-0726
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 E CALIFORNIA ST
Second Line	:
City	:	GAINESVILLE
State	:	TX
Zip	:	76240-4005
Country	:	US
Telephone Number	:	940-665-0726
Fax Number	:

Authorized Official
Title or Position	:	DR-OWNER
Name	:	DR. BRYCE GATES
Credential	:	DDS
Telephone Number	:	214-616-1574

Provider Enumeration Date	:	04/02/2025
Last Update Date	:	04/02/2025

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