Provider Demographics
NPI:1609967959
Name:EGBERT, GREG WAYNE (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:WAYNE
Last Name:EGBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20036 HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:AL
Mailing Address - Zip Code:35188-3733
Mailing Address - Country:US
Mailing Address - Phone:205-938-9727
Mailing Address - Fax:
Practice Address - Street 1:20036 HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:AL
Practice Address - Zip Code:35188-3733
Practice Address - Country:US
Practice Address - Phone:205-938-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKLNO 5506122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist