Provider Demographics
NPI:1255740577
Name:GREELEY DENTAL, PROFESSIONAL LLC
Entity type:Organization
Organization Name:GREELEY DENTAL, PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDRATENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-304-1273
Mailing Address - Street 1:3766 W 10TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-1823
Mailing Address - Country:US
Mailing Address - Phone:970-304-1273
Mailing Address - Fax:970-304-6979
Practice Address - Street 1:3766 W 10TH ST
Practice Address - Street 2:STE A
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-1823
Practice Address - Country:US
Practice Address - Phone:970-304-1273
Practice Address - Fax:970-304-6979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31476538Medicaid