Provider Demographics
NPI:1144588559
Name:SHANBOUR, GREGORY FARRIS (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:FARRIS
Last Name:SHANBOUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604B NEXTON SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7914
Mailing Address - Country:US
Mailing Address - Phone:405-650-0337
Mailing Address - Fax:
Practice Address - Street 1:604B NEXTON SQUARE DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7914
Practice Address - Country:US
Practice Address - Phone:405-650-0337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK65491223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty