Healthcare Provider Details

I. General information

NPI: 1205980414
Provider Name (Legal Business Name): ROBERT LEE GREGORSOK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W 1ST ST
CEDAR FALLS IA
50613-2113
US

IV. Provider business mailing address

1301 W 1ST ST
CEDAR FALLS IA
50613-2113
US

V. Phone/Fax

Practice location:
  • Phone: 319-277-4600
  • Fax: 319-266-5270
Mailing address:
  • Phone: 319-277-4600
  • Fax: 319-266-5270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number08289
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number08289
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: