Provider Demographics
NPI:1548715758
Name:BRUSSELL, GREGORY (DMD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BRUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 CHAMBERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2573
Mailing Address - Country:US
Mailing Address - Phone:502-348-6404
Mailing Address - Fax:502-348-6342
Practice Address - Street 1:919 CHAMBERS BLVD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2573
Practice Address - Country:US
Practice Address - Phone:502-348-6404
Practice Address - Fax:502-348-6342
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY98471223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist