Provider Demographics
NPI:1326021650
Name:GREGG, GARY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:THOMAS
Last Name:GREGG
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 1:700 N DEVINE RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6964
Mailing Address - Country:US
Mailing Address - Phone:360-750-1385
Mailing Address - Fax:360-750-1798
Practice Address - Street 1:700 N DEVINE RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6964
Practice Address - Country:US
Practice Address - Phone:360-750-1385
Practice Address - Fax:360-750-1798
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000058281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADELTA DENTALOtherINSURANCE IDENTIFIER
WADE00005828OtherWA DENTAL LICENSE #
WA073914000OtherBLUE CROSS/BLUE SHIELD