Provider Demographics
NPI:1609138528
Name:GREGG, ERIC L (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:L
Last Name:GREGG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BARTON RD APT 2410
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5447
Mailing Address - Country:US
Mailing Address - Phone:503-550-8054
Mailing Address - Fax:
Practice Address - Street 1:14689 VALLEY CENTER DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4200
Practice Address - Country:US
Practice Address - Phone:503-550-8054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631461223G0001X
ORD9716122300000X
NV6274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist