Provider Demographics
NPI:1487868337
Name:GRELLNER, THEODORE J (DDS PA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:GRELLNER
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15310 AMBERLY DR
Mailing Address - Street 2:SUITE 195
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2199
Mailing Address - Country:US
Mailing Address - Phone:813-972-3478
Mailing Address - Fax:813-972-1782
Practice Address - Street 1:15310 AMBERLY DR
Practice Address - Street 2:SUITE 195
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2199
Practice Address - Country:US
Practice Address - Phone:813-972-3478
Practice Address - Fax:813-972-1782
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL114561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22790Medicare UPIN