Provider Demographics
NPI:1669109229
Name:JEFFERSON, GREGORY TRANDON LEE
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:TRANDON LEE
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 AUSTIN POINT DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-5603
Mailing Address - Country:US
Mailing Address - Phone:910-624-6765
Mailing Address - Fax:
Practice Address - Street 1:865 OILFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-2702
Practice Address - Country:US
Practice Address - Phone:406-434-3142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25964122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist