Provider Demographics
NPI:1689359499
Name:GREEN, KILEY (DDS)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:YATES CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:66783-1259
Mailing Address - Country:US
Mailing Address - Phone:620-625-2185
Mailing Address - Fax:
Practice Address - Street 1:109 W BUTLER ST
Practice Address - Street 2:
Practice Address - City:YATES CENTER
Practice Address - State:KS
Practice Address - Zip Code:66783-1259
Practice Address - Country:US
Practice Address - Phone:620-625-2185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS621261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice