Provider Demographics
NPI:1992946495
Name:JEFFREY S GORMAN DMD, INC.
Entity type:Organization
Organization Name:JEFFREY S GORMAN DMD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:559-449-1275
Mailing Address - Street 1:5646 N PALM SUITE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1848
Mailing Address - Country:US
Mailing Address - Phone:559-449-1275
Mailing Address - Fax:559-449-1282
Practice Address - Street 1:2569 WEST SHAW AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3312
Practice Address - Country:US
Practice Address - Phone:559-449-1275
Practice Address - Fax:559-449-1282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46809261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental