Provider Demographics
NPI:1891916821
Name:GREENLAW, WALTER ROSS JR (DMD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ROSS
Last Name:GREENLAW
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:W.
Other - Middle Name:ROSS
Other - Last Name:GREENLAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:15 CARLETON STREAM LANE
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614
Mailing Address - Country:US
Mailing Address - Phone:207-374-5544
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH STREET
Practice Address - Street 2:BLUE HILL PENINSULA DENTAL
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614
Practice Address - Country:US
Practice Address - Phone:207-374-5538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME28551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice