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General NPI Number Information
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NPI Number | 1720657653
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Entity Type | Individual
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Provider Name | BROOKE GREEN
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Gender | Female
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Dates
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Enumeration Date | 06/24/2021
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Last Update Date | 06/24/2021
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Provider Practice Location Address
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Address Line | 1101 E WALTON BLVD
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City | PONTIAC
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State | MI
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Zip | 48340-1591
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Country | US
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Telephone | 248-499-9989
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Fax |
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Provider Business Mailing Address
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Address Line | 27526 DOREEN ST
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City | FARMINGTON HILLS
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State | MI
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Zip | 48336-6012
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Country | US
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Telephone | 847-849-0606
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901600992
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License Number State | MI
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