1831449412 NPI number — DR. GLENN ANTHONY GREGORY DDS

Table of content: DR. GLENN ANTHONY GREGORY DDS (NPI 1831449412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831449412 NPI number — DR. GLENN ANTHONY GREGORY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGORY
Provider First Name:
GLENN
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831449412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
69 ALLEN ST
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-774-5050
Provider Business Mailing Address Fax Number:
802-774-5042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
69 ALLEN ST
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-774-5050
Provider Business Practice Location Address Fax Number:
802-774-5042
Provider Enumeration Date:
09/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  016.0090235 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1021108 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com