1740902261 NPI number — DR. THOMAS BENJAMIN GRENEKER DMD

Table of content: DR. THOMAS BENJAMIN GRENEKER DMD (NPI 1740902261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740902261 NPI number — DR. THOMAS BENJAMIN GRENEKER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRENEKER
Provider First Name:
THOMAS
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

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:
1740902261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
793 SHILOH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMERICUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31719-8414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-563-1756
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 HUDSON ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31709-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-924-2224
Provider Business Practice Location Address Fax Number:
229-924-4452
Provider Enumeration Date:
09/12/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN122798 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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