Provider Demographics
NPI:1841774734
Name:GREEN, RICHARD DENNIS (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DENNIS
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 1:1158 26TH ST # 556
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4698
Mailing Address - Country:US
Mailing Address - Phone:310-600-5052
Mailing Address - Fax:
Practice Address - Street 1:11980 SAN VICENTE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6604
Practice Address - Country:US
Practice Address - Phone:310-600-5052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD264101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice