Provider Demographics
NPI:1093415309
Name:NIBLACK, GREGORY COLTON
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:COLTON
Last Name:NIBLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2602
Mailing Address - Country:US
Mailing Address - Phone:208-500-5894
Mailing Address - Fax:
Practice Address - Street 1:801 E MEDICAL CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7298
Practice Address - Country:US
Practice Address - Phone:208-773-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60710711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice