Provider Demographics
NPI:1972750396
Name:GREEN, BRIAN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5233 RESIDENCIA
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-9044
Mailing Address - Country:US
Mailing Address - Phone:617-515-2797
Mailing Address - Fax:
Practice Address - Street 1:180 NEWPORT CENTER DR STE 230
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-0903
Practice Address - Country:US
Practice Address - Phone:949-706-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice