MEDICARE: DR. GORDON KEITH GREEN DDS

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	7342	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	457474	OTHER	IN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1265450464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON KEITH GREEN DDS

Provider Business Mailing Address
First Line	:	P O BOX 501
Second Line	:	147 EAST BROAD ST
City	:	LYONS
State	:	IN
Zip	:	47443-9502
Country	:	US
Telephone Number	:	812-659-2111
Fax Number	:	812-659-2808

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	:	812-659-2808

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	12/17/2010

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