Provider Demographics
NPI:1366986705
Name:GREEN DENTISTRY PLLC
Entity type:Organization
Organization Name:GREEN DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-648-3653
Mailing Address - Street 1:5029 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4297
Mailing Address - Country:US
Mailing Address - Phone:801-648-3653
Mailing Address - Fax:
Practice Address - Street 1:707 24TH ST
Practice Address - Street 2:STE 2A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2580
Practice Address - Country:US
Practice Address - Phone:801-648-3653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-04
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7692415-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty