Provider Demographics
NPI:1174855589
Name:GAMBLE, VIRDISLAND CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:VIRDISLAND
Middle Name:CHARLES
Last Name:GAMBLE
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 1:7120 FM 1464 RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-6400
Mailing Address - Country:US
Mailing Address - Phone:713-340-1300
Mailing Address - Fax:281-271-8617
Practice Address - Street 1:7120 FM 1464 RD
Practice Address - Street 2:SUITEB
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-6400
Practice Address - Country:US
Practice Address - Phone:713-340-1300
Practice Address - Fax:281-271-8617
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181558101Medicaid