MEDICARE: DR. MARK RAYMOND 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	12008310	IN

General Provider Information

NPI Number	:	1841209962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RAYMOND GREEN D.D.S.

Provider Business Mailing Address
First Line	:	2201 LINCOLN WAY W
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-2513
Country	:	US
Telephone Number	:	574-232-4990
Fax Number	:	574-232-2470

Provider Business Practice Location Address
First Line	:	2201 LINCOLN WAY WEST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-2513
Country	:	US
Telephone Number	:	574-232-4990
Fax Number	:	574-232-2470

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

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	07/08/2007

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