Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 5707 | NC |
NPI | 1942298443 |
---|---|
Provider Name | Dr. Ronald Dale Gaitros |
First Address | Wilmington, NC 28401-7305 |
Second Address | Wilmington, NC 28401-7305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 07/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8993034 | (05) | NC |
93034 | BLUE CROSS BLUE SHIELD # (01) | NC |
U25927 | (02) | NC |