Provider Demographics
NPI:1902870587
Name:AN, GREGORY K (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:AN
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 WOODSIDE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3497
Mailing Address - Country:US
Mailing Address - Phone:650-369-2555
Mailing Address - Fax:
Practice Address - Street 1:1690 WOODSIDE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3497
Practice Address - Country:US
Practice Address - Phone:650-369-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA200191223G0001X, 1223P0221X
CA590881223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHV0085OtherHARVARD PILGRIM