1972614717 NPI number — DR. DOUGLAS GREEN DDS

Table of content: DR. DOUGLAS GREEN DDS (NPI 1972614717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972614717 NPI number — DR. DOUGLAS GREEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
DOUGLAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972614717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2826 ASPEN LAKE DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55449-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-964-9172
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10729 TOWN SQUARE DR NE
Provider Second Line Business Practice Location Address:
#150
Provider Business Practice Location Address City Name:
BLAINE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-269-8650
Provider Business Practice Location Address Fax Number:
763-201-3377
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D11370 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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