Provider Demographics
NPI:1659333599
Name:GREEN, BRUCE GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:GREGORY
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 1:15438 FOREST OAK ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4951
Mailing Address - Country:US
Mailing Address - Phone:504-874-1309
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVENUE
Practice Address - Street 2:DEPARTMENT OF COMPREHENSIVE DENTISTRY
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-295-0145
Practice Address - Fax:301-295-0505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice