Provider Demographics
NPI:1235109539
Name:GELLA, GREG MICHAEL
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:MICHAEL
Last Name:GELLA
Suffix:
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 1:1120 LEGEND BLVD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-8381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:828 HAWTHORNE ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3252
Practice Address - Country:US
Practice Address - Phone:651-774-2959
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist