Healthcare Provider Details

I. General information

NPI: 1225114085
Provider Name (Legal Business Name): GREGORY EDWARD DOERFLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 DUANE ST SUITE 301
GLEN ELLYN IL
60137-4501
US

IV. Provider business mailing address

493 DUANE ST SUITE 301
GLEN ELLYN IL
60137-4501
US

V. Phone/Fax

Practice location:
  • Phone: 630-858-5755
  • Fax: 630-858-5760
Mailing address:
  • Phone: 630-858-5755
  • Fax: 630-858-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: