Provider Demographics
NPI:1811049091
Name:GREEN, KOURTENAY V (DDS)
Entity type:Individual
Prefix:DR
First Name:KOURTENAY
Middle Name:V
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 1:5920 PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63147-1116
Mailing Address - Country:US
Mailing Address - Phone:314-869-6900
Mailing Address - Fax:
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-268-6135
Practice Address - Fax:314-268-6117
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040132391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice