Provider Demographics
NPI:1902889900
Name:GREENBAUM, KENNETH ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:GREENBAUM
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:34 NORTHVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1072
Mailing Address - Country:US
Mailing Address - Phone:503-699-7758
Mailing Address - Fax:503-699-1194
Practice Address - Street 1:2450 LANCASTER DR NE
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1130
Practice Address - Country:US
Practice Address - Phone:503-362-9548
Practice Address - Fax:503-362-2189
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics