Healthcare Provider Details

I. General information

NPI: 1679239859
Provider Name (Legal Business Name): GINA LEA GREEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 N 71 BUSINESS HWY
ANDERSON MO
64831-9753
US

IV. Provider business mailing address

PO BOX 758
NEOSHO MO
64850-0758
US

V. Phone/Fax

Practice location:
  • Phone: 417-845-2273
  • Fax: 417-845-0094
Mailing address:
  • Phone: 417-451-9450
  • Fax: 417-451-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2014022979
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: