Provider Demographics
NPI:1174810840
Name:GREENWAY 40 LLC
Entity type:Organization
Organization Name:GREENWAY 40 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-595-1115
Mailing Address - Street 1:4022 E GREENWAY RD
Mailing Address - Street 2:STE 13
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4799
Mailing Address - Country:US
Mailing Address - Phone:602-595-1115
Mailing Address - Fax:
Practice Address - Street 1:4022 E GREENWAY RD
Practice Address - Street 2:STE 13
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4797
Practice Address - Country:US
Practice Address - Phone:602-595-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ4044122300000X
AZAZ3740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty