Provider Demographics
NPI:1942592977
Name:RANDI GREEN D.M.D., LLC
Entity Type:Organization
Organization Name:RANDI GREEN D.M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:417-887-5155
Mailing Address - Street 1:2053 S WAVERLY AVE STE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2497
Mailing Address - Country:US
Mailing Address - Phone:417-887-5155
Mailing Address - Fax:417-823-7497
Practice Address - Street 1:2053 S WAVERLY AVE STE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2497
Practice Address - Country:US
Practice Address - Phone:417-887-5155
Practice Address - Fax:417-823-7497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110123151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty