Provider Demographics
NPI:1093032146
Name:GERMINO, GREGORY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
Last Name:GERMINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:THOMAS
Other - Last Name:GERMINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:9763 W 143RD ST STE A
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2575
Mailing Address - Country:US
Mailing Address - Phone:708-349-3443
Mailing Address - Fax:
Practice Address - Street 1:9763 W 143RD ST STE A
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2575
Practice Address - Country:US
Practice Address - Phone:708-349-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190283491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice