Basic Information
| Provider Information | |||||||||
| NPI: | 1629606181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIELSEN | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 LEE ST # 800740 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349241774 | ||||||||
| FaxNumber: | 4342436378 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 BOSTON RD | ||||||||
| Address2: | |||||||||
| City: | NORTH BILLERICA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018622635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783916783 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2020 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | DN1859444 | MA | Y | Dental Providers | Dentist | General Practice | 122300000X | DN1859444 | MA | N | Dental Providers | Dentist |
No ID Information.