Provider Demographics
NPI:1619919545
Name:GREGORY, MARK (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2762 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4859
Mailing Address - Country:US
Mailing Address - Phone:972-698-8500
Mailing Address - Fax:972-698-8505
Practice Address - Street 1:2762 N GALLOWAY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4859
Practice Address - Country:US
Practice Address - Phone:972-698-8500
Practice Address - Fax:972-698-8505
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery