MEDICARE: GREEN DENTAL STUDIO

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	105403	CO

General Provider Information

NPI Number	:	1053521211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN DENTAL STUDIO

Provider Business Mailing Address
First Line	:	6851 S HOLLY CIR STE 250
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1050
Country	:	US
Telephone Number	:	303-770-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	6851 S HOLLY CIR STE 250
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80112-1050
Country	:	US
Telephone Number	:	303-770-3333
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RICHARD E GREEN
Credential	:	D.D.S., M.P.H.
Telephone Number	:	303-770-3333

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/07/2013

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Directions to “GREEN DENTAL STUDIO ” Practice Location

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