Provider Demographics
NPI:1780018317
Name:JOSEPHSEN, GREGORY THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THOMAS
Last Name:JOSEPHSEN
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 1:1111 PARK AVE
Mailing Address - Street 2:APT. 1609
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5656
Mailing Address - Country:US
Mailing Address - Phone:201-953-0468
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:BLALOCK 266
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-6663
Practice Address - Fax:410-614-9747
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDJ66973028310864122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist