Provider Demographics
NPI:1629196944
Name:GREGORY, CARRIE L (DENTAL HYGENTIST)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DENTAL HYGENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202B MAIN ST
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1911
Mailing Address - Country:US
Mailing Address - Phone:573-748-5671
Mailing Address - Fax:573-748-5317
Practice Address - Street 1:202B MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-1911
Practice Address - Country:US
Practice Address - Phone:573-748-5671
Practice Address - Fax:573-748-5317
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003003714124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist