Healthcare Provider Details

I. General information

NPI: 1306066956
Provider Name (Legal Business Name): JONATHAN GREENBURG, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD STE 120
ENCINO CA
91316-5200
US

IV. Provider business mailing address

24981 PALMILLA DR
CALABASAS CA
91302-3053
US

V. Phone/Fax

Practice location:
  • Phone: 818-205-1122
  • Fax: 818-386-8963
Mailing address:
  • Phone: 818-205-1122
  • Fax: 818-386-8963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30452
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number30452
License Number StateCA

VIII. Authorized Official

Name: JONATHAN GIL GREENBURG
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 818-205-1122