Provider Demographics
NPI:1043433451
Name:LONG BRANCH DENTAL GROUP, DEL G. GREGORY, D.D.S., PC
Entity Type:Organization
Organization Name:LONG BRANCH DENTAL GROUP, DEL G. GREGORY, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-385-3413
Mailing Address - Street 1:1609 MAFFRY AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-1960
Mailing Address - Country:US
Mailing Address - Phone:660-385-3413
Mailing Address - Fax:660-385-7069
Practice Address - Street 1:1609 MAFFRY AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1960
Practice Address - Country:US
Practice Address - Phone:660-385-3413
Practice Address - Fax:660-385-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty