Provider Demographics
NPI:1336232826
Name:STRULL, GREGORY EVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EVAN
Last Name:STRULL
Suffix:
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 1:4122 SHELBYVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-896-4401
Mailing Address - Fax:502-893-4930
Practice Address - Street 1:4122 SHELBYVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-896-4401
Practice Address - Fax:502-893-4930
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY64221223S0112X
IN12009303A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000044615OtherANTHEM BCBS
IN100001530AMedicaid
KYU68903Medicare UPIN
KY000000044615OtherANTHEM BCBS