Provider Demographics
NPI:1750412177
Name:GREMBAN, GREGORY ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
Last Name:GREMBAN
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 1:865 N. RAILROAD STREET
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-8834
Mailing Address - Country:US
Mailing Address - Phone:715-479-6100
Mailing Address - Fax:715-477-2162
Practice Address - Street 1:865 N RAILROAD ST
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-8834
Practice Address - Country:US
Practice Address - Phone:715-479-6100
Practice Address - Fax:715-477-2162
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5242-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-1875755OtherTIN