Provider Demographics
NPI:1942394036
Name:BOB, GREGORY RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RICHARD
Last Name:BOB
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 1:5382 HARROW LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 CRAIN HWY
Practice Address - Street 2:SUITE O
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2810
Practice Address - Country:US
Practice Address - Phone:301-843-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD109651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice