Provider Demographics
NPI:1427216415
Name:LETICA, GREGORY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:LETICA
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 1:403 FORT SALONGA RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3045
Mailing Address - Country:US
Mailing Address - Phone:631-261-4477
Mailing Address - Fax:
Practice Address - Street 1:403 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3045
Practice Address - Country:US
Practice Address - Phone:631-261-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY378611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice