Provider Demographics
NPI:1518976976
Name:DERRY, GREGORY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:DERRY
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 1:75 E BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-1300
Mailing Address - Country:US
Mailing Address - Phone:309-647-2244
Mailing Address - Fax:309-647-8829
Practice Address - Street 1:75 E BIRCH ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-1300
Practice Address - Country:US
Practice Address - Phone:309-647-2244
Practice Address - Fax:309-647-8829
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19162361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice