Provider Demographics
NPI:1104029065
Name:VICKIE S GREENBERG A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:VICKIE S GREENBERG A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:VICKIE S GREENBERG A PROFESSIONAL DENTAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-798-7645
Mailing Address - Street 1:2035 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-2444
Mailing Address - Country:US
Mailing Address - Phone:626-798-7645
Mailing Address - Fax:626-798-7089
Practice Address - Street 1:2035 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-2444
Practice Address - Country:US
Practice Address - Phone:626-798-7645
Practice Address - Fax:626-798-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty