MEDICARE: DR. TERRY LEROY 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	1223G0001X	General Practice Dentistry	D4888	AZ

General Provider Information

NPI Number	:	1518080159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY LEROY GREEN D.D.S.

Provider Business Mailing Address
First Line	:	1101 SE TECH CENTER DR
Second Line	:	SUITE 195
City	:	VANCOUVER
State	:	WA
Zip	:	98683-5504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4570 N ORACLE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85705-1638
Country	:	US
Telephone Number	:	520-888-0510
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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