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General NPI Number Information
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NPI Number | 1053615831
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Entity Type | Individual
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Provider Name | DR. IVAN L GREEN
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Gender | Male
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Dates
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Enumeration Date | 01/07/2011
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Last Update Date | 01/07/2011
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Provider Practice Location Address
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Address Line | 19551 E 10 MILE RD
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City | ROSEVILLE
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State | MI
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Zip | 48066-3998
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Country | US
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Telephone | 586-775-6770
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Fax |
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Provider Business Mailing Address
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Address Line | 29961 NORTHBROOK ST
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-2328
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Country | US
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Telephone | 248-797-7795
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901009700
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License Number State | MI
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