=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992449854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STANLEY W. GRESHAM DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2022
-----------------------------------------------------
Last Update Date | 05/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 E AURORA ST
-----------------------------------------------------
City | IRONWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49938-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-932-2730
-----------------------------------------------------
Fax | 906-932-5832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 E AURORA ST
-----------------------------------------------------
City | IRONWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49938-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-932-2730
-----------------------------------------------------
Fax | 906-932-5832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STANLEY W GRESHAM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 906-932-2730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------