Healthcare Provider Details

I. General information

NPI: 1801812714
Provider Name (Legal Business Name): BRENDAN RODNEY GREEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 NORTH 400 EAST
NORTH OGDEN UT
84414
US

IV. Provider business mailing address

2707 N 400 E
NORTH OGDEN UT
84414-2241
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-0866
  • Fax: 801-782-0866
Mailing address:
  • Phone: 801-782-0866
  • Fax: 801-782-0866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5340572
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: