Provider Demographics
NPI:1447284773
Name:GASSAWAY, JERRY W
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:GASSAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 STOCKDALE HWY STE A
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-2059
Mailing Address - Country:US
Mailing Address - Phone:661-324-8055
Mailing Address - Fax:661-324-7141
Practice Address - Street 1:4000 STOCKDALE HWY STE A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-2059
Practice Address - Country:US
Practice Address - Phone:661-324-8055
Practice Address - Fax:661-324-7141
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA264021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice