Provider Demographics
NPI:1063639425
Name:DALE, GREGORY W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:DALE
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 1:7832 N KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64119-4528
Mailing Address - Country:US
Mailing Address - Phone:816-436-2558
Mailing Address - Fax:
Practice Address - Street 1:2109 NE 72ND ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-2304
Practice Address - Country:US
Practice Address - Phone:816-452-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE014667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431679108OtherTAX ID