Basic Information
| Provider Information | |||||||||
| NPI: | 1578640488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTARELLI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | DDS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5017 GREEN BAY RD | ||||||||
| Address2: | SUITE 138 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626546770 | ||||||||
| FaxNumber: | 2626546727 | ||||||||
| Practice Location | |||||||||
| Address1: | 5017 GREEN BAY RD | ||||||||
| Address2: | SUITE 138 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626546770 | ||||||||
| FaxNumber: | 2626546727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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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 | 1223S0112X | 5188015 | WI | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.