Provider Demographics
NPI:1649720475
Name:GREENLAW, STACY DAWN (RDH)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:DAWN
Last Name:GREENLAW
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 BLOOMSBURY RUN
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1974
Mailing Address - Country:US
Mailing Address - Phone:603-490-9023
Mailing Address - Fax:
Practice Address - Street 1:1845 HOLSONBACK DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5114
Practice Address - Country:US
Practice Address - Phone:386-274-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22124124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist