Provider Demographics
NPI:1669684353
Name:GRUBBA, GREGORY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
Last Name:GRUBBA
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 1:4200 LAKE OTIS PKWY
Mailing Address - Street 2:#301
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-562-1958
Mailing Address - Fax:907-561-1696
Practice Address - Street 1:4200 LAKE OTIS
Practice Address - Street 2:#301
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-562-1958
Practice Address - Fax:907-561-1696
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA 731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist