Provider Demographics
NPI:1366532095
Name:GREEN, GREGORY EUGENE (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EUGENE
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 1:500 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1829
Mailing Address - Country:US
Mailing Address - Phone:715-235-1106
Mailing Address - Fax:715-235-1107
Practice Address - Street 1:500 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1829
Practice Address - Country:US
Practice Address - Phone:715-235-1106
Practice Address - Fax:715-235-1107
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2871-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice