Provider Demographics
NPI:1912076985
Name:GREEN, LARRY PAUL SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:PAUL
Last Name:GREEN
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:PO BOX 243 102 N EGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042
Mailing Address - Country:US
Mailing Address - Phone:605-256-4969
Mailing Address - Fax:605-256-4717
Practice Address - Street 1:102 N EGAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042
Practice Address - Country:US
Practice Address - Phone:605-256-4969
Practice Address - Fax:605-256-4717
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist