Provider Demographics
NPI:1053356493
Name:GANT, DEAN ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ALAN
Last Name:GANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 QUEENS RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3253
Mailing Address - Country:US
Mailing Address - Phone:704-333-7376
Mailing Address - Fax:704-333-3397
Practice Address - Street 1:1005 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2205
Practice Address - Country:US
Practice Address - Phone:704-591-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC321452085R0001X
VA01012228662085R0001X
NC2009-016852085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912746Medicaid
SCNC1003Medicaid
NC2075313CMedicare PIN
NC5912746Medicaid
NC2075313DMedicare PIN
NC2075313BMedicare PIN
SCAA45486058Medicare PIN