Provider Demographics
NPI:1174645345
Name:GREEN, ALAN EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:EDWARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5926
Mailing Address - Country:US
Mailing Address - Phone:303-543-8555
Mailing Address - Fax:303-543-1236
Practice Address - Street 1:625 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5926
Practice Address - Country:US
Practice Address - Phone:303-543-8555
Practice Address - Fax:303-543-1236
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO71381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice