Provider Demographics
NPI:1427078351
Name:GERTSEN, GREGORY ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:GERTSEN
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 1:1155 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1202
Mailing Address - Country:US
Mailing Address - Phone:605-882-3060
Mailing Address - Fax:605-882-0681
Practice Address - Street 1:1155 4TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1202
Practice Address - Country:US
Practice Address - Phone:605-882-3060
Practice Address - Fax:605-882-0681
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7804320Medicaid