Healthcare Provider Details

I. General information

NPI: 1285735530
Provider Name (Legal Business Name): DENNIS M GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SAWTELLE BLVD
LOS ANGELES CA
90025-7014
US

IV. Provider business mailing address

23388 MULHOLLAND DR MAILSTOP 62
WOODLAND HILLS CA
91364-2733
US

V. Phone/Fax

Practice location:
  • Phone: 310-996-9355
  • Fax: 310-312-4913
Mailing address:
  • Phone: 310-996-9355
  • Fax: 310-312-4913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG55353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: