Provider Demographics
NPI:1144363813
Name:PATRICK, GARY W (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:PATRICK
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 1:9059 W LAKE PLEASANT PKWY
Mailing Address - Street 2:SUITE D400
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8336
Mailing Address - Country:US
Mailing Address - Phone:623-572-0303
Mailing Address - Fax:
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY
Practice Address - Street 2:SUITE D400
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8336
Practice Address - Country:US
Practice Address - Phone:623-572-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1744690OtherUNITED CONCORDIA TRICARE
AZAZ0105011OtherBCBS OF AZ