Provider Demographics
NPI:1164489266
Name:WEBER, GREGORY STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:STEPHEN
Last Name:WEBER
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:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009
Mailing Address - Country:US
Mailing Address - Phone:507-263-3965
Mailing Address - Fax:507-263-9485
Practice Address - Street 1:925 4TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009
Practice Address - Country:US
Practice Address - Phone:507-263-3965
Practice Address - Fax:507-263-9485
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice