Provider Demographics
NPI:1033277942
Name:GREEN, LEVI G (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEVI
Middle Name:G
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 1:703 LILLY RD NE STE 201
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5256
Mailing Address - Country:US
Mailing Address - Phone:360-459-3400
Mailing Address - Fax:360-459-9700
Practice Address - Street 1:703 LILLY RD NE STE 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5256
Practice Address - Country:US
Practice Address - Phone:360-459-3400
Practice Address - Fax:360-459-9700
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099861223G0001X
WA99861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1879363OtherUNITED CONCORDIA PROVIDER
WA0210215OtherL & I PROVIDER NUMBER
WA5051099Medicaid