Provider Demographics
NPI:1396778312
Name:GORMAN, GREGORY J (DMD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:GORMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 W. 400N.
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2236
Mailing Address - Country:US
Mailing Address - Phone:435-259-4333
Mailing Address - Fax:435-259-6618
Practice Address - Street 1:570 W. 400N.
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2236
Practice Address - Country:US
Practice Address - Phone:435-259-4333
Practice Address - Fax:435-259-6618
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT311259-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice