Healthcare Provider Details

I. General information

NPI: 1588658520
Provider Name (Legal Business Name): GREGORY L WIGTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S BELLWOOD DR A
EAST ALTON IL
62024-2086
US

IV. Provider business mailing address

160 S BELLWOOD DR A
EAST ALTON IL
62024-2086
US

V. Phone/Fax

Practice location:
  • Phone: 618-258-0239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: