Provider Demographics
NPI:1942305719
Name:DILLAWAY, GREGG RUSSELL (DMD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:RUSSELL
Last Name:DILLAWAY
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:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-0001
Mailing Address - Country:US
Mailing Address - Phone:781-899-5084
Mailing Address - Fax:781-642-0609
Practice Address - Street 1:30 COLPITTS RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1534
Practice Address - Country:US
Practice Address - Phone:781-899-5084
Practice Address - Fax:781-642-0609
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX06467DIOtherBCBS PROVIDER
MA807OtherDELTA DENTAL PROVIDER
MA17525OtherMA STATE LICENSE
MAMD0251708COtherMA STATE DRUG LICENSE
MA17525OtherMA STATE LICENSE