Provider Demographics
NPI:1811077142
Name:SOUTH, GREGORY R (DMD PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:SOUTH
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:R
Other - Last Name:SOUTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD PA
Mailing Address - Street 1:112 HARMON LANE
Mailing Address - Street 2:SUITE A
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284
Mailing Address - Country:US
Mailing Address - Phone:336-993-3751
Mailing Address - Fax:336-993-6601
Practice Address - Street 1:112 HARMON LANE
Practice Address - Street 2:SUITE A
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284
Practice Address - Country:US
Practice Address - Phone:336-993-3751
Practice Address - Fax:336-993-6601
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice