Healthcare Provider Details

I. General information

NPI: 1821494386
Provider Name (Legal Business Name): KENNETH D. GREENSTADT D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3565 TORRANCE BLVD SUITE B
TORRANCE CA
90503-4847
US

IV. Provider business mailing address

3565 TORRANCE BLVD SUITE B
TORRANCE CA
90503-4847
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-6262
  • Fax:
Mailing address:
  • Phone: 310-792-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number24300
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number24300
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH DOUGLAS GREENSTADT
Title or Position: OWNER
Credential: DDS
Phone: 310-792-6262