Provider Demographics
NPI:1437438421
Name:GREEN, DAVID LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
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 1:1805 ARKANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-4244
Mailing Address - Country:US
Mailing Address - Phone:509-876-7270
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMSON ST., BLDG 237
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:509-876-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2456122300000X
WADE 60223505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist