Provider Demographics
NPI:1073336483
Name:GATEWAY ORAL SURGERY
Entity type:Organization
Organization Name:GATEWAY ORAL SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-200-4375
Mailing Address - Street 1:180 CAPULET DR STE 3
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-4541
Mailing Address - Country:US
Mailing Address - Phone:904-299-2942
Mailing Address - Fax:904-299-2943
Practice Address - Street 1:180 CAPULET DR STE 3
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-4541
Practice Address - Country:US
Practice Address - Phone:904-299-2942
Practice Address - Fax:904-299-2943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-04
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty