Healthcare Provider Details

I. General information

NPI: 1417240888
Provider Name (Legal Business Name): JOHN GREEN DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 S STATE ST SUITE 103
OREM UT
84097-8237
US

IV. Provider business mailing address

1256 S STATE ST SUITE 103
OREM UT
84097-8237
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-7182
  • Fax: 801-235-0835
Mailing address:
  • Phone: 801-224-7182
  • Fax: 801-235-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7692415-9922
License Number StateUT

VIII. Authorized Official

Name: DR. JOHN GREEN
Title or Position: OWNER, DOCTOR
Credential: DMD
Phone: 801-224-7182