Basic Information
| Provider Information | |||||||||
| NPI: | 1770533861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERDERBER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 DUPONT CIR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135767700 | ||||||||
| FaxNumber: | 5135761020 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 STERN RD | ||||||||
| Address2: | |||||||||
| City: | SEAMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456799607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373861379 | ||||||||
| FaxNumber: | 9373860129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/23/2009 | ||||||||
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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 | 1223G0001X | 30-01-8697 | OH | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0689183 | 05 | OH | MEDICAID |