Provider Demographics
NPI:1134678006
Name:MICHAEL L GREEN, DDS, INC
Entity Type:Organization
Organization Name:MICHAEL L GREEN, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-483-7354
Mailing Address - Street 1:2821 EASTERN AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5445
Mailing Address - Country:US
Mailing Address - Phone:916-483-7354
Mailing Address - Fax:916-483-1390
Practice Address - Street 1:2821 EASTERN AVE STE 5
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5445
Practice Address - Country:US
Practice Address - Phone:916-483-7354
Practice Address - Fax:916-483-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherDENTIST