Provider Demographics
NPI:1780746024
Name:ATWOOD, GREGORY JAN (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAN
Last Name:ATWOOD
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 1:2455 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4232
Mailing Address - Country:US
Mailing Address - Phone:432-337-6165
Mailing Address - Fax:432-337-5204
Practice Address - Street 1:2455 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4232
Practice Address - Country:US
Practice Address - Phone:432-337-6165
Practice Address - Fax:432-337-5204
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice