Healthcare Provider Details

I. General information

NPI: 1770732208
Provider Name (Legal Business Name): BRETMGREENDDSPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 CANDELARIA RD NE SUITE A2
ALBUQUERQUE NM
87112-1034
US

IV. Provider business mailing address

8501 CANDELARIA RD NE SUITE A2
ALBUQUERQUE NM
87112-1034
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-9606
  • Fax:
Mailing address:
  • Phone: 505-299-9606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2322
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2141
License Number StateNM

VIII. Authorized Official

Name: DR. BRET MICHAEL GREEN
Title or Position: DR.
Credential: DDS
Phone: 505-299-9606