Basic Information
| Provider Information | |||||||||
| NPI: | 1861559866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORELL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 EAST EDISON AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098373090 | ||||||||
| FaxNumber: | 5098373414 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 EAST EDISON AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098373090 | ||||||||
| FaxNumber: | 5098373414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7925 | WA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 5034491 | 05 | WA | MEDICAID |