Provider Demographics
NPI:1992768857
Name:GATEWAY FAMILY DENTISTRY, INC.
Entity type:Organization
Organization Name:GATEWAY FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-857-0745
Mailing Address - Street 1:805 E WARNER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1000
Mailing Address - Country:US
Mailing Address - Phone:480-857-0745
Mailing Address - Fax:480-917-8955
Practice Address - Street 1:805 E WARNER RD
Practice Address - Street 2:STE 100
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1000
Practice Address - Country:US
Practice Address - Phone:480-857-0745
Practice Address - Fax:480-917-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ858665Medicare ID - Type UnspecifiedAHCCCS