Provider Demographics
NPI:1962375428
Name:GREENLEAF ORTHODONTICS - PARK CITY LLC
Entity type:Organization
Organization Name:GREENLEAF ORTHODONTICS - PARK CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:LABLONDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-965-0810
Mailing Address - Street 1:355 GREENLEAF ST STE D
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5708
Mailing Address - Country:US
Mailing Address - Phone:262-758-6038
Mailing Address - Fax:888-475-7136
Practice Address - Street 1:355 GREENLEAF ST STE D
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:IL
Practice Address - Zip Code:60085-5708
Practice Address - Country:US
Practice Address - Phone:262-758-6038
Practice Address - Fax:888-475-7136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-29
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty