Healthcare Provider Details

I. General information

NPI: 1487868337
Provider Name (Legal Business Name): THEODORE J GRELLNER D.D.S. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15310 AMBERLY DR SUITE 195
TAMPA FL
33647-2199
US

IV. Provider business mailing address

15310 AMBERLY DR SUITE 195
TAMPA FL
33647-2199
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-3478
  • Fax: 813-972-1782
Mailing address:
  • Phone: 813-972-3478
  • Fax: 813-972-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: