=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831313782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE TERESE GREEN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5122 OLYMPIC DR NW SUITE B 201
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-851-8151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5122 OLYMPIC DR NW SUITE B 201
-----------------------------------------------------
City | GIG HARBOR
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98335-1767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-851-8151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 10650
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------