Provider Demographics
NPI:1245497528
Name:GREENBERG DENTAL SPECIALTY GROUP
Entity type:Organization
Organization Name:GREENBERG DENTAL SPECIALTY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-772-5124
Mailing Address - Street 1:926 GREAT POND DR STE 2003
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:926 GREAT POND DR STE 2003
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-7244
Practice Address - Country:US
Practice Address - Phone:407-788-6533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1821026576OtherGREENBERG DENTAL GENERAL NPI#
FL592960505OtherGREENBERG GENERAL DENTIST TIN#