Provider Demographics
NPI:1093102055
Name:GREENE, KEVIN JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JEFFREY
Last Name:GREENE
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 1:6420 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-6592
Mailing Address - Country:US
Mailing Address - Phone:608-222-8080
Mailing Address - Fax:
Practice Address - Street 1:6420 COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-6592
Practice Address - Country:US
Practice Address - Phone:608-222-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001151-15122300000X
390200000X
AL6387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program