Provider Demographics
NPI:1841779915
Name:GREGG, JESSIE (DDS)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
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:CMR 414 BOX 1304
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09173-0014
Mailing Address - Country:US
Mailing Address - Phone:931-217-8253
Mailing Address - Fax:
Practice Address - Street 1:968 1ST INFANTRY DIVISION RD
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5210
Practice Address - Country:US
Practice Address - Phone:502-626-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN107481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN359990000OtherUS ARMY