MEDICARE: MRS. THERESA ANN GREEN RDA

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	126800000X	Dental Assistant	DA0000010736	TN

General Provider Information

NPI Number	:	1629269931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA ANN GREEN RDA

Provider Business Mailing Address
First Line	:	P.O. BOX 2339
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042-2339
Country	:	US
Telephone Number	:	931-553-0919
Fax Number	:	931-553-0971

Provider Business Practice Location Address
First Line	:	1573 FORT CAMPBELL BLVD
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37042-3535
Country	:	US
Telephone Number	:	931-553-0919
Fax Number	:	931-553-0971

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

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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