Provider Demographics
NPI:1154731156
Name:WAY, GREGORY ALLEN II
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:WAY
Suffix:II
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 1:1955 DEER PARK AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1253
Mailing Address - Country:US
Mailing Address - Phone:865-748-3492
Mailing Address - Fax:
Practice Address - Street 1:3935 DUPONT CIR STE D
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4824
Practice Address - Country:US
Practice Address - Phone:502-897-0424
Practice Address - Fax:502-897-0427
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9444122300000X
KY539001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist