Healthcare Provider Details

I. General information

NPI: 1114238128
Provider Name (Legal Business Name): JEFFREY BOYD GREGERSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14005 N HWY 183 STE 800
AUSTIN TX
78717-5960
US

IV. Provider business mailing address

3401 EL SALIDO PKWY
CEDAR PARK TX
78613-2550
US

V. Phone/Fax

Practice location:
  • Phone: 512-644-1752
  • Fax: 512-266-6197
Mailing address:
  • Phone: 512-401-8888
  • Fax: 512-401-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS038229
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number25245
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: