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General NPI Number Information
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NPI Number | 1215080734
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Entity Type | Organization
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Legal Business Name | GREEN COUNTRY DENTURE CENTER
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 1824 S.E . WASHINGTON BLVD.
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City | BARTLESVILLE
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State | OK
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Zip | 74006
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Country | US
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Telephone | 918-331-2221
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Fax | 918-336-1052
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Provider Business Mailing Address
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Address Line | 1824 S.E . WASHINGTON BLVD. PO BOX 3248
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City | BARTLESVILLE
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State | OK
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Zip | 74006
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Country | US
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Telephone | 918-331-2221
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Fax | 918-336-1052
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN LARD
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Credential | DDS
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Telephone | 918-331-2221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5779
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5431
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License Number State | OK
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