Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | DN15027 | FL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | ME77063 | FL |
N | 208200000X | Surgeon | ME77063 | FL |
N | 208600000X | Surgeon | ME77063 | FL |
NPI | 1255306866 |
---|---|
Provider Name | Dr. Lance Francis Grenevicki |
First Address | West Melbourne, FL 32904-1652 |
Second Address | West Melbourne, FL 32904-1652 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/02/2006 |
Last Update Date | 21/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U77510 | (02) | FL |