MEDICARE: FREEDOM DENTAL SELECT DE LLC

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

General Provider Information

NPI Number	:	1952289746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEDOM DENTAL SELECT DE LLC

Provider Business Mailing Address
First Line	:	2006 LIMESTONE RD STE 5
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19808-5553
Country	:	US
Telephone Number	:	302-299-5617
Fax Number	:

Provider Business Practice Location Address
First Line	:	19643 BLUE BIRD LN
Second Line	:
City	:	REHOBOTH BEACH
State	:	DE
Zip	:	19971-6129
Country	:	US
Telephone Number	:	302-227-3257
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KYLE GREEN
Credential	:	DDS
Telephone Number	:	302-563-4599

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	08/21/2025

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