Provider Demographics
NPI:1649232521
Name:GREEN, LANCE DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:DAVID
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 1:1225 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-445-5692
Mailing Address - Fax:925-445-5313
Practice Address - Street 1:1225 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-445-5692
Practice Address - Fax:925-445-5313
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDEA#BG202645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist