1902889900 NPI number — DR. KENNETH ROBERT GREENBAUM DDS, MS

Table of content: DR. KENNETH ROBERT GREENBAUM DDS, MS (NPI 1902889900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902889900 NPI number — DR. KENNETH ROBERT GREENBAUM DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENBAUM
Provider First Name:
KENNETH
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
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:
1902889900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 NORTHVIEW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-1072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-699-7758
Provider Business Mailing Address Fax Number:
503-699-1194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 LANCASTER DR NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97305-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-362-9548
Provider Business Practice Location Address Fax Number:
503-362-2189
Provider Enumeration Date:
11/22/2005

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: 1223X0400X , with the licence number:  4701 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com