MEDICARE: DR. KEVAN S GREEN DMD

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	1223P0300X	Periodontics	22DI01467000	NJ
2	1223P0300X	Periodontics	DS024064L	PA

General Provider Information

NPI Number	:	1518008093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVAN S GREEN DMD

Provider Business Mailing Address
First Line	:	215 E BALTIMORE AVE
Second Line	:
City	:	CLIFTON HEIGHTS
State	:	PA
Zip	:	19018-1605
Country	:	US
Telephone Number	:	610-623-4493
Fax Number	:	610-623-0871

Provider Business Practice Location Address
First Line	:	215 E BALTIMORE AVE
Second Line	:
City	:	CLIFTON HEIGHTS
State	:	PA
Zip	:	19018-1605
Country	:	US
Telephone Number	:	610-623-4493
Fax Number	:	610-623-0871

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	05/12/2008

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