Healthcare Provider Details

I. General information

NPI: 1316066723
Provider Name (Legal Business Name): JAMES ROYCE GREEN D.D.S., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KELL BLVD.
WICHITA FALLS TX
76309
US

IV. Provider business mailing address

2200 KELL BLVD.
WICHITA FALLS TX
76309
US

V. Phone/Fax

Practice location:
  • Phone: 940-322-2252
  • Fax: 940-322-7090
Mailing address:
  • Phone: 940-322-2252
  • Fax: 940-322-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD16192
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: