Provider Demographics
NPI:1245629518
Name:GREENE, COLLEEN (DMD, MPH)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7900 HARWOOD AVE
Mailing Address - Street 2:APT. 111
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2554
Mailing Address - Country:US
Mailing Address - Phone:810-394-6539
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:DENTAL CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2040
Practice Address - Fax:414-266-5677
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7288-151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245629518Medicaid