MEDICARE: MR. RICHARD EDWARD GREEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	105403	CO

General Provider Information

NPI Number	:	1063622629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD EDWARD GREEN D.D.S.

Provider Business Mailing Address
First Line	:	6851 S HOLLY CIR STE 250
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1050
Country	:	US
Telephone Number	:	303-770-3333
Fax Number	:	303-770-3333

Provider Business Practice Location Address
First Line	:	6851 S HOLLY CIR STE 250
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1050
Country	:	US
Telephone Number	:	303-770-3333
Fax Number	:	303-770-3333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/06/2013

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