Provider Demographics
NPI:1023189404
Name:GREGIE, KENNETH JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:GREGIE
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 1:413 W SAINT CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2432
Mailing Address - Country:US
Mailing Address - Phone:630-629-3120
Mailing Address - Fax:630-629-3167
Practice Address - Street 1:413 W SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2432
Practice Address - Country:US
Practice Address - Phone:630-629-3120
Practice Address - Fax:630-629-3167
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190152011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice