Provider Demographics
NPI:1053960500
Name:GREENWAY DENTAL LAB INC.
Entity type:Organization
Organization Name:GREENWAY DENTAL LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FRKETICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-242-2303
Mailing Address - Street 1:1855 W GREENWAY RD STE 109
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-3475
Mailing Address - Country:US
Mailing Address - Phone:602-242-2303
Mailing Address - Fax:
Practice Address - Street 1:1855 W GREENWAY RD STE 109
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-3475
Practice Address - Country:US
Practice Address - Phone:602-242-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-07
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126900000XDental ProvidersDental Laboratory TechnicianGroup - Single Specialty