Provider Demographics
NPI:1588795041
Name:GRECO, MICHAEL ANGELO (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGELO
Last Name:GRECO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 FREESTATE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6540
Mailing Address - Country:US
Mailing Address - Phone:318-221-8002
Mailing Address - Fax:318-221-4447
Practice Address - Street 1:111 FREESTATE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6540
Practice Address - Country:US
Practice Address - Phone:318-221-8002
Practice Address - Fax:318-221-4447
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA36871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice