Provider Demographics
NPI:1669581278
Name:GREEN, NICOLE RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
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 1:10450 185TH ST W
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6686
Mailing Address - Country:US
Mailing Address - Phone:952-435-9888
Mailing Address - Fax:952-435-9820
Practice Address - Street 1:10450 185TH ST W
Practice Address - Street 2:SUITE 500
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6686
Practice Address - Country:US
Practice Address - Phone:952-435-9888
Practice Address - Fax:952-435-9820
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0110631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice