MEDICARE: DR. BROOKS ANDREW GREEN D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12012283A	IN

General Provider Information

NPI Number	:	1003298076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROOKS ANDREW GREEN D.D.S

Provider Business Mailing Address
First Line	:	147 E BROAD ST
Second Line	:
City	:	LYONS
State	:	IN
Zip	:	47443-9502
Country	:	US
Telephone Number	:	812-659-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	147 E BROAD ST
Second Line	:
City	:	LYONS
State	:	IN
Zip	:	47443-9502
Country	:	US
Telephone Number	:	812-659-2111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	06/25/2015

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