Provider Demographics
NPI:1528130820
Name:GRESHAM, STANLEY WEIR (DDS)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:WEIR
Last Name:GRESHAM
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 1:212 E AURORA ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2112
Mailing Address - Country:US
Mailing Address - Phone:906-932-2730
Mailing Address - Fax:906-932-5832
Practice Address - Street 1:220 S SUFFOLK ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-2128
Practice Address - Country:US
Practice Address - Phone:906-932-2730
Practice Address - Fax:906-932-5832
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010110511223G0001X
WI45730151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124042930Medicaid
WI33401100Medicaid