Provider Demographics
NPI:1083742928
Name:GREEN, BRAD (DDS)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
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:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:AR
Mailing Address - Zip Code:72727-0293
Mailing Address - Country:US
Mailing Address - Phone:479-445-6919
Mailing Address - Fax:479-445-6920
Practice Address - Street 1:2421 N CENTER ST STE D
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-9609
Practice Address - Country:US
Practice Address - Phone:479-445-7281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR35781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice