Provider Demographics
NPI:1346483211
Name:POWELL, GREGORY JOE (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOE
Last Name:POWELL
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 1:12255 DE PAUL DR.
Mailing Address - Street 2:STE 885
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-298-0727
Mailing Address - Fax:314-298-9151
Practice Address - Street 1:12255 DE PAUL DR.
Practice Address - Street 2:STE 885
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-298-0727
Practice Address - Fax:314-298-9151
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0121481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics