Provider Demographics
NPI:1639264757
Name:SMOCK, GREGORY THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
Last Name:SMOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-0277
Mailing Address - Country:US
Mailing Address - Phone:763-263-3470
Mailing Address - Fax:763-263-5900
Practice Address - Street 1:29 LAKE ST S
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4588
Practice Address - Country:US
Practice Address - Phone:763-263-3470
Practice Address - Fax:763-263-5900
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor