Provider Demographics
NPI:1366186868
Name:GREENE, ELIZABETH MARIE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2846 SHADOW RD
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-9497
Mailing Address - Country:US
Mailing Address - Phone:715-201-6739
Mailing Address - Fax:
Practice Address - Street 1:N2846 SHADOW RD
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-9497
Practice Address - Country:US
Practice Address - Phone:715-201-6739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI60011151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program