Provider Demographics
NPI:1306984869
Name:HERBSTER, GREG ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:ALAN
Last Name:HERBSTER
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 1:5707 US 31 S
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-5318
Mailing Address - Country:US
Mailing Address - Phone:574-291-2132
Mailing Address - Fax:
Practice Address - Street 1:5707 US 31 S
Practice Address - Street 2:SUITE #2
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-5318
Practice Address - Country:US
Practice Address - Phone:574-291-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120093561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice