Provider Demographics
NPI:1164626883
Name:GREENE, KEIRA VALE (DDS)
Entity Type:Individual
Prefix:
First Name:KEIRA
Middle Name:VALE
Last Name:GREENE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 N GOVERNMENT WAY STE 44
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8256
Mailing Address - Country:US
Mailing Address - Phone:303-810-9296
Mailing Address - Fax:
Practice Address - Street 1:8636 N WAYNE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5084
Practice Address - Country:US
Practice Address - Phone:303-810-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4879122300000X
VA0401412653122300000X
CO9781122300000X
TX23323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-4879OtherDENTAL LICENSE
TX23323OtherDENTAL LICENSE