Healthcare Provider Details

I. General information

NPI: 1245379619
Provider Name (Legal Business Name): RICHARD JOHN GREEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 DEMOCRACY BLVD
BETHESDA MD
20817-1664
US

IV. Provider business mailing address

6300 DEMOCRACY BLVD
BETHESDA MD
20817-1664
US

V. Phone/Fax

Practice location:
  • Phone: 301-530-6902
  • Fax:
Mailing address:
  • Phone: 301-530-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10238
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: