Provider Demographics
NPI:1578130175
Name:DEREK GREEN DMD LLC
Entity Type:Organization
Organization Name:DEREK GREEN DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-370-0696
Mailing Address - Street 1:4361 BONIFACE PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4314
Mailing Address - Country:US
Mailing Address - Phone:907-333-1211
Mailing Address - Fax:907-743-2925
Practice Address - Street 1:4361 BONIFACE PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4314
Practice Address - Country:US
Practice Address - Phone:907-333-1211
Practice Address - Fax:907-743-2925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEREK GREEN DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1684562Medicaid