MEDICARE: GILMORE ORTHODONTICS DENTAL PRACTICE

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1518726702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GILMORE ORTHODONTICS DENTAL PRACTICE

Provider Business Mailing Address
First Line	:	9870 HIBERT ST STE D9
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-1091
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9870 HIBERT ST STE D9
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-1091
Country	:	US
Telephone Number	:	858-433-7377
Fax Number	:

Authorized Official
Title or Position	:	FINANCIAL COORDINATOR
Name	:	KELLY GODDEYNE
Credential	:
Telephone Number	:	858-433-7377

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	03/18/2024

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