MEDICARE: BRADLEY W 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	1223D0004X	Dental Anesthesiology	DEN.00202624	CO

General Provider Information

NPI Number	:	1689935975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY W GREEN DDS

Provider Business Mailing Address
First Line	:	1745 SHEA CENTER DR FL 4
Second Line	:
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80129-1537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1745 SHEA CENTER DR FL 4
Second Line	:
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80129-1537
Country	:	US
Telephone Number	:	720-606-4220
Fax Number	:

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

Provider Enumeration Date	:	06/03/2012
Last Update Date	:	08/04/2015

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