Healthcare Provider Details

I. General information

NPI: 1699959726
Provider Name (Legal Business Name): GREGORY ALLEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S.W MAIN BLVD.
LAKE CITY FL
32025
US

IV. Provider business mailing address

255 S.W. MAIN BLVD.
LAKE CITY FL
32025
US

V. Phone/Fax

Practice location:
  • Phone: 386-752-2480
  • Fax: 386-755-8757
Mailing address:
  • Phone: 386-752-2480
  • Fax: 386-755-8757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN00008820
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN00008820
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: