Provider Demographics
NPI:1497952923
Name:GREENE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:GREENE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-889-8427
Mailing Address - Street 1:65 SACHEM ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-4201
Mailing Address - Country:US
Mailing Address - Phone:860-889-8427
Mailing Address - Fax:860-204-9402
Practice Address - Street 1:65 SACHEM ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-4201
Practice Address - Country:US
Practice Address - Phone:860-889-8427
Practice Address - Fax:860-204-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009537261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental