Provider Demographics
NPI:1447273768
Name:GOTTFRIED, MYRON LEON (DDS)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:LEON
Last Name:GOTTFRIED
Suffix:
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 1:215 JUSTICE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CANDLER
Mailing Address - State:NC
Mailing Address - Zip Code:28715-9575
Mailing Address - Country:US
Mailing Address - Phone:828-665-6666
Mailing Address - Fax:828-259-9189
Practice Address - Street 1:1415 PATTON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-1721
Practice Address - Country:US
Practice Address - Phone:828-254-9692
Practice Address - Fax:828-259-9189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC42841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC93293OtherBCBSNC