Provider Demographics
NPI:1104919463
Name:ST CLAIR, GREGORY THADDEUS (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THADDEUS
Last Name:ST CLAIR
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 1:101 HOYT LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1318
Mailing Address - Country:US
Mailing Address - Phone:631-928-1957
Mailing Address - Fax:
Practice Address - Street 1:101 HOYT LN
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1318
Practice Address - Country:US
Practice Address - Phone:631-928-1957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0436751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice