Provider Demographics
NPI:1851304034
Name:FOSSUM, GREGORY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:FOSSUM
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 1:9301 S PADRE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-5505
Mailing Address - Country:US
Mailing Address - Phone:361-937-5555
Mailing Address - Fax:361-937-6668
Practice Address - Street 1:9301 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-5505
Practice Address - Country:US
Practice Address - Phone:361-937-5555
Practice Address - Fax:361-937-6668
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0143971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice