Healthcare Provider Details

I. General information

NPI: 1629606181
Provider Name (Legal Business Name): GREGORY NIELSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 10/06/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 BOSTON RD
NORTH BILLERICA MA
01862-2635
US

IV. Provider business mailing address

1215 LEE ST # 800740
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 978-391-6783
  • Fax:
Mailing address:
  • Phone: 434-924-1774
  • Fax: 434-243-6378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859444
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1859444
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: