Healthcare Provider Details

I. General information

NPI: 1487205233
Provider Name (Legal Business Name): J.R. GREGG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE 223RD AVE STE 220
GRESHAM OR
97030-2578
US

IV. Provider business mailing address

1720 N. OLD BRUCEVILLE RD.
VINCENNES IN
47591
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-4546
  • Fax:
Mailing address:
  • Phone: 812-887-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JOSEPH RANDALL GREGG
Title or Position: ORTHODONTIST/OWNER
Credential: DDS, MSD
Phone: 812-887-1960