Provider Demographics
NPI:1689107559
Name:GREEN DENTAL OF OWEN COUNTY
Entity Type:Organization
Organization Name:GREEN DENTAL OF OWEN COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BROOKS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-829-2261
Mailing Address - Street 1:51 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IN
Mailing Address - Zip Code:47460-1311
Mailing Address - Country:US
Mailing Address - Phone:812-829-2261
Mailing Address - Fax:812-829-2263
Practice Address - Street 1:51 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460-1311
Practice Address - Country:US
Practice Address - Phone:812-829-2261
Practice Address - Fax:812-829-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012283A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty