Healthcare Provider Details

I. General information

NPI: 1609967959
Provider Name (Legal Business Name): GREG WAYNE EGBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20036 HIGHWAY 11
WOODSTOCK AL
35188-3733
US

IV. Provider business mailing address

20036 HIGHWAY 11
WOODSTOCK AL
35188-3733
US

V. Phone/Fax

Practice location:
  • Phone: 205-938-9727
  • Fax:
Mailing address:
  • Phone: 205-938-9727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberLNO 5506
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: