=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790560597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LE GREENFIELD DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2023
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 274 N EL CAMINO REAL STE D
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-436-5580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 274 N EL CAMINO REAL STE D
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-436-5580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROLL LE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-426-5580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------