Provider Demographics
NPI:1073189049
Name:KAISER, GREGORY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:KAISER
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 1:1483 STARCROSS LN APT 105
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46280-2987
Mailing Address - Country:US
Mailing Address - Phone:260-417-0350
Mailing Address - Fax:
Practice Address - Street 1:4341 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4400
Practice Address - Country:US
Practice Address - Phone:260-493-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013625A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist