Provider Demographics
NPI:1083900021
Name:CALLOWAY, GREGORY ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
Last Name:CALLOWAY
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 1:3001 GREEN BAY RD
Mailing Address - Street 2:USS OSBORNE, BLDG 1017 JAMES A. LOVELL FHCC
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3048
Mailing Address - Country:US
Mailing Address - Phone:847-688-2100
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:USS OSBORNE, BLDG 1017 JAMES A. LOVELL FHCC
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:847-688-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110144331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice