Provider Demographics
NPI:1205883279
Name:GREGORY, EDWARD SIDNEY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:SIDNEY
Last Name:GREGORY
Suffix:JR
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 1:31 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575
Mailing Address - Country:US
Mailing Address - Phone:516-546-7782
Mailing Address - Fax:516-546-7782
Practice Address - Street 1:2094 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207
Practice Address - Country:US
Practice Address - Phone:516-546-7782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist