Provider Demographics
NPI:1730212283
Name:STEWART, GREGORY RAYMOND (DMD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RAYMOND
Last Name:STEWART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 S ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4069
Mailing Address - Country:US
Mailing Address - Phone:815-397-5615
Mailing Address - Fax:
Practice Address - Street 1:1393 S ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4069
Practice Address - Country:US
Practice Address - Phone:815-397-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice