Provider Demographics
NPI:1578640488
Name:SANTARELLI, GREGORY A (DDS SC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:SANTARELLI
Suffix:
Gender:M
Credentials:DDS SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 GREEN BAY RD
Mailing Address - Street 2:SUITE 138
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1782
Mailing Address - Country:US
Mailing Address - Phone:262-654-6770
Mailing Address - Fax:262-654-6727
Practice Address - Street 1:5017 GREEN BAY RD
Practice Address - Street 2:SUITE 138
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1782
Practice Address - Country:US
Practice Address - Phone:262-654-6770
Practice Address - Fax:262-654-6727
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51880151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV0325Medicare UPIN
WI00017992Medicare PIN