Provider Demographics
NPI:1386232791
Name:J GREGG ORTHO LLC
Entity type:Organization
Organization Name:J GREGG ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:812-887-1960
Mailing Address - Street 1:755 ANCHORS WAY
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-9051
Mailing Address - Country:US
Mailing Address - Phone:812-887-1960
Mailing Address - Fax:
Practice Address - Street 1:755 ANCHORS WAY
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511-9051
Practice Address - Country:US
Practice Address - Phone:812-887-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty