Provider Demographics
NPI:1164874046
Name:GREGG, NICHOLAS (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GREGG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19606 STATE ROAD 20 W
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-3916
Mailing Address - Country:US
Mailing Address - Phone:850-674-5502
Mailing Address - Fax:
Practice Address - Street 1:19606 STATE ROAD 20 W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-3916
Practice Address - Country:US
Practice Address - Phone:850-674-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist