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General NPI Number Information
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NPI Number | 1952580094
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Entity Type | Organization
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Legal Business Name | DR. GREGORY LEE DERRY D.D.S. LTD
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Dates
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Enumeration Date | 10/25/2007
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 75 E BIRCH ST
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City | CANTON
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State | IL
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Zip | 61520-1300
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Country | US
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Telephone | 309-647-2244
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Fax |
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Provider Business Mailing Address
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Address Line | 75 E BIRCH ST
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City | CANTON
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State | IL
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Zip | 61520-1300
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Country | US
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Telephone | 309-647-2244
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GREGORY LEE DERRY
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Credential | D.D.S.
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Telephone | 309-647-2244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1916263
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License Number State | IL
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