MEDICARE: GREEN MEADOWS FAMILY DENTISTRY

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1134811870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN MEADOWS FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	4676 PRINCESS ANNE RD STE 100
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6465
Country	:	US
Telephone Number	:	757-495-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	4676 PRINCESS ANNE RD STE 100
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6465
Country	:	US
Telephone Number	:	757-495-5010
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	DONNA RENEE JOHNSON
Credential	:
Telephone Number	:	757-357-4121

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/22/2023

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Directions to “GREEN MEADOWS FAMILY DENTISTRY ” Practice Location

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