Healthcare Provider Details

I. General information

NPI: 1255306866
Provider Name (Legal Business Name): LANCE FRANCIS GRENEVICKI MD, DDS, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 S WICKHAM RD THE INSTITUTE OF FACIAL SURGERY
WEST MELBOURNE FL
32904-1652
US

IV. Provider business mailing address

1093 S WICKHAM RD THE INSTITUTE OF FACIAL SURGERY
WEST MELBOURNE FL
32904-1652
US

V. Phone/Fax

Practice location:
  • Phone: 321-674-3900
  • Fax: 321-722-3303
Mailing address:
  • Phone: 321-674-3900
  • Fax: 321-722-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15027
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME77063
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME77063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: