Provider Demographics
NPI:1063434124
Name:RACKAUSKAS, GREGORY GEORGE (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GEORGE
Last Name:RACKAUSKAS
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 1:213 MAYS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:309-663-5440
Mailing Address - Fax:
Practice Address - Street 1:305 SOUTH LINDEN
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-454-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190149631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice