Healthcare Provider Details

I. General information

NPI: 1073053120
Provider Name (Legal Business Name): LUKE NATHANIEL GREENE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 06 3500 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

MSC 06 3500 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax: 505-925-4030
Mailing address:
  • Phone: 505-925-4031
  • Fax: 505-925-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN-DEN-LIC-15398
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: