Provider Demographics
NPI:1558488668
Name:GREGG, JOSEPH RANDALL (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:RANDALL
Last Name:GREGG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-2127
Mailing Address - Country:US
Mailing Address - Phone:812-882-7867
Mailing Address - Fax:812-882-7085
Practice Address - Street 1:429 PERRY ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-2127
Practice Address - Country:US
Practice Address - Phone:812-882-7867
Practice Address - Fax:812-882-7085
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120097611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics