Provider Demographics
NPI:1518007582
Name:GREEN, PHILIP P (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:P
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 SW 153RD DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4166
Mailing Address - Country:US
Mailing Address - Phone:503-646-7101
Mailing Address - Fax:503-646-7105
Practice Address - Street 1:3925 SW 153RD DR
Practice Address - Street 2:SUITE #100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4166
Practice Address - Country:US
Practice Address - Phone:503-646-7101
Practice Address - Fax:503-646-7105
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD50481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORROOWCKFBCMedicare PIN
ORT67668Medicare UPIN