Provider Demographics
NPI:1477606267
Name:HARTLEY, GREGORY W (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:HARTLEY
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 1:24615 MARSH LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2138
Mailing Address - Country:US
Mailing Address - Phone:904-285-9799
Mailing Address - Fax:
Practice Address - Street 1:4181 SOUTHPOINT DR E
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0993
Practice Address - Country:US
Practice Address - Phone:904-737-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN103001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
63218AMedicare PIN