1376930990 NPI number — GREENFIELD OPTIMAL DENTAL CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376930990 NPI number — GREENFIELD OPTIMAL DENTAL CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREENFIELD OPTIMAL DENTAL CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376930990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3670 S. 108TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-837-5989
Provider Business Mailing Address Fax Number:
414-837-5992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3670 S 108TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53228-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-837-5989
Provider Business Practice Location Address Fax Number:
414-837-5992
Provider Enumeration Date:
04/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
IGWIKE
Authorized Official First Name:
EMMANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER/PART OWNER
Authorized Official Telephone Number:
414-837-5989

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5519 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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