Healthcare Provider Details

I. General information

NPI: 1689359499
Provider Name (Legal Business Name): KILEY GREEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 N 7TH ST
FREDONIA KS
66736-1315
US

IV. Provider business mailing address

428 N 7TH ST
FREDONIA KS
66736-1315
US

V. Phone/Fax

Practice location:
  • Phone: 620-378-2001
  • Fax: 620-378-4697
Mailing address:
  • Phone: 620-378-2001
  • Fax: 620-378-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62126
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: