MEDICARE: DR. GREGORY CLARK BRISCOE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2207	WV

General Provider Information

NPI Number	:	1962406876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY CLARK BRISCOE DDS

Provider Business Mailing Address
First Line	:	PO BOX 13485
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25360-0485
Country	:	US
Telephone Number	:	304-984-0052
Fax Number	:	304-984-3140

Provider Business Practice Location Address
First Line	:	2018 MARTINS BRANCH RD
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25312-9457
Country	:	US
Telephone Number	:	304-984-0052
Fax Number	:	304-984-3140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	10/18/2012

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