Provider Demographics
NPI:1730771353
Name:GREENHAVEN FAMILY DENTAL LLC
Entity type:Organization
Organization Name:GREENHAVEN FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:PIELAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-412-5034
Mailing Address - Street 1:925 SECRET RIVER DR STE A
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3465
Mailing Address - Country:US
Mailing Address - Phone:916-421-3815
Mailing Address - Fax:
Practice Address - Street 1:925 SECRET RIVER DR STE A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3465
Practice Address - Country:US
Practice Address - Phone:916-421-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty