Provider Demographics
NPI:1821105388
Name:GREENE, THOMAS R
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 BRENTWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2190
Mailing Address - Country:US
Mailing Address - Phone:925-634-3501
Mailing Address - Fax:925-634-1539
Practice Address - Street 1:6440 BRENTWOOD BLVD STE B
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2190
Practice Address - Country:US
Practice Address - Phone:925-634-3501
Practice Address - Fax:925-634-1539
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist