MEDICARE: DR. MARVIN 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		IL

General Provider Information

NPI Number	:	1669692372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARVIN GREENE D.D.S.

Provider Business Mailing Address
First Line	:	220 SURREY LN
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-3474
Country	:	US
Telephone Number	:	847-295-6096
Fax Number	:

Provider Business Practice Location Address
First Line	:	2449 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2414
Country	:	US
Telephone Number	:	773-327-2400
Fax Number	:	773-327-4759

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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