Provider Demographics
NPI:1649245614
Name:GREEN, KENNETH PETER (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PETER
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 1:5310 CONNECTICUT AVE NW
Mailing Address - Street 2:#5
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1852
Mailing Address - Country:US
Mailing Address - Phone:202-577-5105
Mailing Address - Fax:202-537-7117
Practice Address - Street 1:NATIONAL NAVAL MEDICAL CENTER
Practice Address - Street 2:8901 WISCONSIN AVENUE
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:202-762-3032
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0363121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY036312OtherDENTISTRY