Provider Demographics
NPI:1326599903
Name:OPAL DENTAL, PC
Entity Type:Organization
Organization Name:OPAL DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-305-2449
Mailing Address - Street 1:85 ARGONAUT STE 220
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4105
Mailing Address - Country:US
Mailing Address - Phone:949-305-2449
Mailing Address - Fax:
Practice Address - Street 1:85 ARGONAUT STE 220
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4105
Practice Address - Country:US
Practice Address - Phone:949-305-2449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty