Basic Information
Provider Information
NPI: 1003296781
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GREENLAND
FirstName: ROBERT
MiddleName: GRAHAM
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 200 1ST ST SW
Address2:  
City: ROCHESTER
State: MN
PostalCode: 559050001
CountryCode: US
TelephoneNumber: 5072842511
FaxNumber:  
Practice Location
Address1: 200 1ST ST SW
Address2:  
City: ROCHESTER
State: MN
PostalCode: 559050001
CountryCode: US
TelephoneNumber: 5072842511
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/08/2015
LastUpdateDate: 11/03/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223S0112XD13571MNY Dental ProvidersDentistOral and Maxillofacial Surgery
204E00000XD13571MNN Allopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery 

No ID Information.


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