Provider Demographics
NPI:1871649624
Name:SUTHERLAND, GREGG A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:A
Last Name:SUTHERLAND
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 1:3135 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9615
Mailing Address - Country:US
Mailing Address - Phone:906-226-8186
Mailing Address - Fax:906-226-2497
Practice Address - Street 1:3135 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-9615
Practice Address - Country:US
Practice Address - Phone:906-226-8186
Practice Address - Fax:906-226-2497
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI120131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4583027Medicaid