Provider Demographics
NPI:1255306866
Name:GRENEVICKI, LANCE FRANCIS (MD, DDS, FACS)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:FRANCIS
Last Name:GRENEVICKI
Suffix:
Gender:M
Credentials:MD, DDS, FACS
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Mailing Address - Street 1:1093 S WICKHAM RD
Mailing Address - Street 2:THE INSTITUTE OF FACIAL SURGERY
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1652
Mailing Address - Country:US
Mailing Address - Phone:321-674-3900
Mailing Address - Fax:321-722-3303
Practice Address - Street 1:1093 S WICKHAM RD
Practice Address - Street 2:THE INSTITUTE OF FACIAL SURGERY
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1652
Practice Address - Country:US
Practice Address - Phone:321-674-3900
Practice Address - Fax:321-722-3303
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME77063204E00000X, 208600000X
FLDN150271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU77510Medicare UPIN