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General NPI Number Information
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NPI Number | 1366986705
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Entity Type | Organization
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Legal Business Name | GREEN DENTISTRY PLLC
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Dates
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Enumeration Date | 12/04/2016
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Last Update Date | 12/04/2016
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Provider Practice Location Address
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Address Line | 707 24TH ST STE 2A
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City | OGDEN
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State | UT
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Zip | 84401-2580
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Country | US
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Telephone | 801-648-3653
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Fax |
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Provider Business Mailing Address
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Address Line | 5029 S 1200 E
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City | OGDEN
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State | UT
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Zip | 84403-4297
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Country | US
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Telephone | 801-648-3653
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN GREEN
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Credential | DMD
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Telephone | 801-648-3653
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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 | 7692415-9922
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License Number State | UT
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