Provider Demographics
NPI:1992449854
Name:STANLEY W. GRESHAM DDS
Entity type:Organization
Organization Name:STANLEY W. GRESHAM DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-932-2730
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 1:212 E AURORA ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-2112
Practice Address - Country:US
Practice Address - Phone:906-932-2730
Practice Address - Fax:906-932-5832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33401100Medicaid
MI1528130820Medicaid