Provider Demographics
NPI:1700809969
Name:EGBERT, GREGORY WILLIAM (DDS, MSD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E 3900 SO
Mailing Address - Street 2:STE 210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1367
Mailing Address - Country:US
Mailing Address - Phone:801-265-1500
Mailing Address - Fax:801-265-9963
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:STE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1367
Practice Address - Country:US
Practice Address - Phone:801-265-1500
Practice Address - Fax:801-265-9963
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143512204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery