MEDICARE: KEVIN JEFFREY GREENE 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	122300000X	Dentist	1001151-15	WI
2	390200000X	Student in an Organized Health Care Education/Training Program
3	122300000X	Dentist	6387	AL

General Provider Information

NPI Number	:	1093102055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN JEFFREY GREENE D.D.S.

Provider Business Mailing Address
First Line	:	6420 COTTAGE GROVE RD
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-6592
Country	:	US
Telephone Number	:	608-222-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	6420 COTTAGE GROVE RD
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-6592
Country	:	US
Telephone Number	:	608-222-8080
Fax Number	:

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

Provider Enumeration Date	:	04/16/2015
Last Update Date	:	04/06/2021

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