Provider Demographics
NPI:1497246334
Name:STEWART, GREGORY WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WILSON
Last Name:STEWART
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 1:2805 NE 129TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-26
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7071OtherOKLAHOMA STATE BOARD OF DENTISTRY