Healthcare Provider Details

I. General information

NPI: 1740370519
Provider Name (Legal Business Name): DENA A GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DOBSON RD
MESA AZ
85202-4707
US

IV. Provider business mailing address

1487 S COLT DR
GILBERT AZ
85296-7341
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-4204
  • Fax:
Mailing address:
  • Phone: 608-201-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number40325
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number40325-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: