Provider Demographics
NPI:1407004567
Name:GREEN, COURTNEY ANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:869 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1958
Mailing Address - Country:US
Mailing Address - Phone:860-622-5340
Mailing Address - Fax:860-622-5342
Practice Address - Street 1:15 MERCER AVE
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1517
Practice Address - Country:US
Practice Address - Phone:860-622-5514
Practice Address - Fax:860-622-5342
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006800124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006800OtherSTATE LICENSE