Healthcare Provider Details

I. General information

NPI: 1548367600
Provider Name (Legal Business Name): GREGORY L GLADE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 11TH STREET NORTH
PORT BYRON IL
61275-9038
US

IV. Provider business mailing address

308 11TH STREET NORTH
PORT BYRON IL
61275-9038
US

V. Phone/Fax

Practice location:
  • Phone: 309-523-3325
  • Fax: 309-523-9078
Mailing address:
  • Phone: 309-523-3325
  • Fax: 309-523-9078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: