Provider Demographics
NPI:1225040058
Name:WYSONG, GREGORY PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:WYSONG
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 1:601 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-2562
Mailing Address - Country:US
Mailing Address - Phone:765-659-4977
Mailing Address - Fax:
Practice Address - Street 1:601 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-2562
Practice Address - Country:US
Practice Address - Phone:765-659-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ75411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice