Provider Demographics
NPI:1205941226
Name:GREENE, MICHAEL LAXTON SR (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAXTON
Last Name:GREENE
Suffix:SR
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 1:711 BLUE HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112
Mailing Address - Country:US
Mailing Address - Phone:860-242-4848
Mailing Address - Fax:860-242-8241
Practice Address - Street 1:711 BLUE HILLS AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112
Practice Address - Country:US
Practice Address - Phone:860-242-4848
Practice Address - Fax:860-242-8241
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist