Healthcare Provider Details

I. General information

NPI: 1790878619
Provider Name (Legal Business Name): MARK DEWAYNE GREGSTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 E HAMPDEN AVE #200
DENVER CO
80224-3025
US

IV. Provider business mailing address

7150 E HAMPDEN AVE #200
DENVER CO
80224-3025
US

V. Phone/Fax

Practice location:
  • Phone: 303-758-2366
  • Fax: 303-756-1460
Mailing address:
  • Phone: 303-758-2366
  • Fax: 303-756-1460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8720
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: