Provider Demographics
NPI:1790360329
Name:GREENOUGH, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:GREENOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3568 ISLANDWALK CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-1613
Mailing Address - Country:US
Mailing Address - Phone:239-269-2277
Mailing Address - Fax:
Practice Address - Street 1:3771 TAMIAMI TRL E
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-6253
Practice Address - Country:US
Practice Address - Phone:239-350-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRP2278390200000X
FLDRPM2278390200000X
FL279231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program