Provider Demographics
NPI:1639361843
Name:PO, GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 E BONANZA RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-3557
Mailing Address - Country:US
Mailing Address - Phone:702-307-2273
Mailing Address - Fax:702-307-2275
Practice Address - Street 1:5001 E BONANZA RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-3557
Practice Address - Country:US
Practice Address - Phone:702-307-2273
Practice Address - Fax:702-307-2275
Is Sole Proprietor?:No
Enumeration Date:2007-08-11
Last Update Date:2007-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV44251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice