Provider Demographics
NPI:1154458685
Name:VELLIGAN, GREGORY A (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:VELLIGAN
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 1:10942 FAWN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-9552
Mailing Address - Country:US
Mailing Address - Phone:317-339-2268
Mailing Address - Fax:
Practice Address - Street 1:10942 FAWN LAKE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-9552
Practice Address - Country:US
Practice Address - Phone:317-339-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009273122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200313590Medicaid