Basic Information
Provider Information | |||||||||
NPI: | 1073733820 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRECEANU | ||||||||
FirstName: | IOANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 361 BIRD ST | ||||||||
Address2: |   | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CT | ||||||||
PostalCode: | 066052804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033306000 | ||||||||
FaxNumber: | 2033397192 | ||||||||
Practice Location | |||||||||
Address1: | 361 BIRD ST | ||||||||
Address2: |   | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CT | ||||||||
PostalCode: | 066052804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033306000 | ||||||||
FaxNumber: | 2033397192 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 008596 | CT | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 004236122 | 05 | CT |   | MEDICAID |