Provider Demographics
NPI:1265450464
Name:GREEN, GORDON KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:KEITH
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:P O BOX 501
Mailing Address - Street 2:147 EAST BROAD ST
Mailing Address - City:LYONS
Mailing Address - State:IN
Mailing Address - Zip Code:47443-9502
Mailing Address - Country:US
Mailing Address - Phone:812-659-2111
Mailing Address - Fax:812-659-2808
Practice Address - Street 1:147 E BROAD ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IN
Practice Address - Zip Code:47443-9502
Practice Address - Country:US
Practice Address - Phone:812-659-2111
Practice Address - Fax:812-659-2808
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN73421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124690AMedicaid
IN457474OtherUNITED CONCORDIA