Healthcare Provider Details

I. General information

NPI: 1639160575
Provider Name (Legal Business Name): JOHN MARSHALL GREGG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL PARK DR SE SUITE 1
BLACKSBURG VA
24060-6665
US

IV. Provider business mailing address

100 PROFESSIONAL PARK DR SE SUITE 1
BLACKSBURG VA
24060-6665
US

V. Phone/Fax

Practice location:
  • Phone: 540-951-8777
  • Fax: 540-951-9642
Mailing address:
  • Phone: 540-951-8777
  • Fax: 540-951-9642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401005828
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: