Provider Demographics
NPI:1093413254
Name:BACK, GREGORY DALE I
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DALE
Last Name:BACK
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7518 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3446
Mailing Address - Country:US
Mailing Address - Phone:347-901-0406
Mailing Address - Fax:
Practice Address - Street 1:1275 E 2ND STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005
Practice Address - Country:US
Practice Address - Phone:937-704-0809
Practice Address - Fax:937-704-0820
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician