Provider Demographics
NPI:1720113384
Name:PINE, GREGORY JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:PINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49433 COMPASS PTE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047
Mailing Address - Country:US
Mailing Address - Phone:586-716-4945
Mailing Address - Fax:
Practice Address - Street 1:49095 SCHOENHERR
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-726-8350
Practice Address - Fax:586-731-3965
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI157021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice