Provider Demographics
NPI:1962406876
Name:BRISCOE, GREGORY CLARK (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CLARK
Last Name:BRISCOE
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:PO BOX 13485
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25360-0485
Mailing Address - Country:US
Mailing Address - Phone:304-984-0052
Mailing Address - Fax:304-984-3140
Practice Address - Street 1:2018 MARTINS BRANCH RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-9457
Practice Address - Country:US
Practice Address - Phone:304-984-0052
Practice Address - Fax:304-984-3140
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134805000Medicare ID - Type UnspecifiedPERSONAL
WV012784000Medicare ID - Type UnspecifiedGROUP