=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902469133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY QUATTLEBAUM JR. DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2019
-----------------------------------------------------
Last Update Date | 08/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4953 CASTELLO DR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-8927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-263-2122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4953 CASTELLO DR
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-8927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-263-2122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 24422
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------