Provider Demographics
NPI:1265440192
Name:KUCHTJAK, GREGORY J (DMD PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:KUCHTJAK
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 CAROLINA AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677
Mailing Address - Country:US
Mailing Address - Phone:704-883-8516
Mailing Address - Fax:704-883-8560
Practice Address - Street 1:933 CAROLINA AVENUE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:704-883-8516
Practice Address - Fax:704-883-8560
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry