Healthcare Provider Details

I. General information

NPI: 1467578344
Provider Name (Legal Business Name): STEVEN M GREEN D D S P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/20/2021
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 STATESMEN DR STE A
INDIANAPOLIS IN
46250-5649
US

IV. Provider business mailing address

4745 STATESMEN DR STE A
INDIANAPOLIS IN
46250-5649
US

V. Phone/Fax

Practice location:
  • Phone: 317-482-7900
  • Fax: 317-792-8588
Mailing address:
  • Phone: 317-482-7900
  • Fax: 317-792-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8575
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN MICHAEL GREEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-482-7900