Provider Demographics
NPI:1669453759
Name:ARCHAMBAULT, GREGORY A (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:ARCHAMBAULT
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 1:1414 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4591
Mailing Address - Country:US
Mailing Address - Phone:904-269-3842
Mailing Address - Fax:904-644-8087
Practice Address - Street 1:1414 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4591
Practice Address - Country:US
Practice Address - Phone:904-269-3842
Practice Address - Fax:904-644-8087
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist