Healthcare Provider Details

I. General information

NPI: 1700809654
Provider Name (Legal Business Name): WILLIAM ALLEN GREEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MAIN ST RICHFORD DENTAL CLINIC
RICHFORD VT
05476-1153
US

IV. Provider business mailing address

810 MAQUAM SHORE RD
SWANTON VT
05488-8416
US

V. Phone/Fax

Practice location:
  • Phone: 802-255-5563
  • Fax: 802-255-5569
Mailing address:
  • Phone: 802-524-0930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0160064702
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: