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General NPI Number Information
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NPI Number | 1417240888
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Entity Type | Organization
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Legal Business Name | JOHN GREEN DENTISTRY PC
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Dates
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Enumeration Date | 05/18/2011
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Last Update Date | 05/18/2011
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Provider Practice Location Address
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Address Line | 1256 S STATE ST SUITE 103
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City | OREM
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State | UT
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Zip | 84097-8237
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Country | US
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Telephone | 801-224-7182
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Fax | 801-235-0835
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Provider Business Mailing Address
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Address Line | 1256 S STATE ST SUITE 103
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City | OREM
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State | UT
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Zip | 84097-8237
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Country | US
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Telephone | 801-224-7182
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Fax | 801-235-0835
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Authorized Official
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Title or Position | OWNER, DOCTOR
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Name | DR. JOHN GREEN
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Credential | DMD
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Telephone | 801-224-7182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 7692415-9922
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License Number State | UT
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