Healthcare Provider Details

I. General information

NPI: 1912076985
Provider Name (Legal Business Name): LARRY PAUL GREEN SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N EGAN AVE
MADISON SD
57042
US

IV. Provider business mailing address

PO BOX 243 102 N EGAN AVE
MADISON SD
57042
US

V. Phone/Fax

Practice location:
  • Phone: 605-256-4969
  • Fax: 605-256-4717
Mailing address:
  • Phone: 605-256-4969
  • Fax: 605-256-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberM594
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: