Provider Demographics
NPI:1538218730
Name:ASBURY, GARY KEITH JR (DDS)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:KEITH
Last Name:ASBURY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 KANAWHA TER
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2867
Mailing Address - Country:US
Mailing Address - Phone:304-727-2224
Mailing Address - Fax:304-727-2225
Practice Address - Street 1:200 KANAWHA TER
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2867
Practice Address - Country:US
Practice Address - Phone:304-727-2224
Practice Address - Fax:304-727-2225
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134123000Medicaid