Provider Demographics
NPI:1518096734
Name:SMITH, GREGG LESLIE (DDS)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:LESLIE
Last Name:SMITH
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 1:86 ELSIE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08536-1929
Mailing Address - Country:US
Mailing Address - Phone:609-275-5442
Mailing Address - Fax:
Practice Address - Street 1:1301 MAIN ST
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-5359
Practice Address - Country:US
Practice Address - Phone:732-502-5161
Practice Address - Fax:732-774-0313
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO15501001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223510254OtherTIN NUMBER