Provider Demographics
NPI:1518093939
Name:GREEN, RICHARD STEWART (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:STEWART
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 1:1445 E LOS ANGELES AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2817
Mailing Address - Country:US
Mailing Address - Phone:805-526-8296
Mailing Address - Fax:805-526-9504
Practice Address - Street 1:1445 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2817
Practice Address - Country:US
Practice Address - Phone:805-526-8296
Practice Address - Fax:805-526-9504
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist