=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265450464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON KEITH GREEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 12/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 E BROAD ST
-----------------------------------------------------
City | LYONS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47443-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-659-2111
-----------------------------------------------------
Fax | 812-659-2808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 501 147 EAST BROAD ST
-----------------------------------------------------
City | LYONS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47443-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-659-2111
-----------------------------------------------------
Fax | 812-659-2808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7342
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------