=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104029065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICKIE S GREENBERG A PROFESSIONAL DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 08/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2035 LAKE AVE
-----------------------------------------------------
City | ALTADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91001-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-798-7645
-----------------------------------------------------
Fax | 626-798-7089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2035 LAKE AVE
-----------------------------------------------------
City | ALTADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91001-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-798-7645
-----------------------------------------------------
Fax | 626-798-7089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. VICKIE SUE GREENBERG
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 626-798-7645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 37112
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------