MEDICARE: GREEN COUNTRY DENTURE CENTER

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	5779	OK
2	122300000X	Dentist	5431	OK

General Provider Information

NPI Number	:	1215080734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN COUNTRY DENTURE CENTER

Provider Business Mailing Address
First Line	:	1824 S.E . WASHINGTON BLVD.
Second Line	:	PO BOX 3248
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006
Country	:	US
Telephone Number	:	918-331-2221
Fax Number	:	918-336-1052

Provider Business Practice Location Address
First Line	:	1824 S.E . WASHINGTON BLVD.
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006
Country	:	US
Telephone Number	:	918-331-2221
Fax Number	:	918-336-1052

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN LARD
Credential	:	DDS
Telephone Number	:	918-331-2221

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	06/26/2012

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Directions to “GREEN COUNTRY DENTURE CENTER ” Practice Location

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