Provider Demographics
NPI:1285994947
Name:GREGORY, DERRICK B (DMD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:B
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 W BADDOUR PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2656
Mailing Address - Country:US
Mailing Address - Phone:615-444-0322
Mailing Address - Fax:
Practice Address - Street 1:1430 W BADDOUR PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2656
Practice Address - Country:US
Practice Address - Phone:615-444-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000009457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist