Provider Demographics
NPI:1508073438
Name:SEGRAVES, GREGORY D (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:SEGRAVES
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6132 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-2117
Mailing Address - Country:US
Mailing Address - Phone:918-494-8636
Mailing Address - Fax:918-494-8636
Practice Address - Street 1:6132 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2117
Practice Address - Country:US
Practice Address - Phone:918-494-8634
Practice Address - Fax:918-494-8636
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59301223S0112X
IA301731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery