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General NPI Number Information
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NPI Number | 1811049091
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Entity Type | Individual
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Provider Name | KOURTENAY V GREEN D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 3535 S JEFFERSON AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63118-3930
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Country | US
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Telephone | 314-268-6135
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Fax | 314-268-6117
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Provider Business Mailing Address
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Address Line | 5920 PARK LN
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City | SAINT LOUIS
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State | MO
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Zip | 63147-1116
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Country | US
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Telephone | 314-869-6900
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2004013239
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License Number State | MO
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