Provider Demographics
NPI:1932673217
Name:GREENBERG, KENNETH MARK (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARK
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8529 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3288
Mailing Address - Country:US
Mailing Address - Phone:813-920-6608
Mailing Address - Fax:
Practice Address - Street 1:8529 GUNN HWY
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3288
Practice Address - Country:US
Practice Address - Phone:813-920-6608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN100561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice