Provider Demographics
NPI:1023635422
Name:GREEN, RAQUEL ALICIA (DDS)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:ALICIA
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 1:15390 W CENTERRA DR N APT 52
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4172
Mailing Address - Country:US
Mailing Address - Phone:812-459-0707
Mailing Address - Fax:
Practice Address - Street 1:825 S WATSON RD STE 101
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3435
Practice Address - Country:US
Practice Address - Phone:623-386-7319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0107391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice