Healthcare Provider Details

I. General information

NPI: 1225040058
Provider Name (Legal Business Name): GREGORY PAUL WYSONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E WALNUT ST
FRANKFORT IN
46041-2562
US

IV. Provider business mailing address

601 E WALNUT ST
FRANKFORT IN
46041-2562
US

V. Phone/Fax

Practice location:
  • Phone: 765-659-4977
  • Fax:
Mailing address:
  • Phone: 765-659-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberIN7541
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: