Healthcare Provider Details

I. General information

NPI: 1366435349
Provider Name (Legal Business Name): GREGORY P. VANNUCCI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

1116 PENNSYLVANIA AVE
OTTUMWA IA
52501-2109
US

IV. Provider business mailing address

1116 PENNSYLVANIA AVE
OTTUMWA IA
52501-2109
US

V. Phone/Fax

Practice location:
  • Phone: 641-682-2350
  • Fax: 641-683-4616
Mailing address:
  • Phone: 641-682-2350
  • Fax: 641-683-4616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number07963
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: