Provider Demographics
NPI:1487205233
Name:J.R. GREGG LLC
Entity Type:Organization
Organization Name:J.R. GREGG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:812-887-1960
Mailing Address - Street 1:1720 N. OLD BRUCEVILLE RD.
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-887-1960
Mailing Address - Fax:
Practice Address - Street 1:1201 SE 223RD AVE STE 220
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2578
Practice Address - Country:US
Practice Address - Phone:503-489-4546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty