Basic Information
| Provider Information | |||||||||
| NPI: | 1689998437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 WETZEL AVENUE, BLDG 815 | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY, ATTN: FRAN GERNERT CREDENTIALS | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195265551 | ||||||||
| Practice Location | |||||||||
| Address1: | 4TH & INTERLOOP ROAD BLDG 171 | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY, ATTN: FRAN GERNERT CREDENTIALS | ||||||||
| City: | FORT IRWIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195265551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 07/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 58284 | CA | Y | Dental Providers | Dentist |
No ID Information.