Provider Demographics
NPI:1003296781
Name:GREENLAND, ROBERT GRAHAM (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRAHAM
Last Name:GREENLAND
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 E PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-256-8770
Mailing Address - Fax:616-327-7452
Practice Address - Street 1:1179 E PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-256-8770
Practice Address - Fax:616-327-7452
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016010051223P0700X
MND135711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901601005OtherPROSTHODONTIC LICENSE