Provider Demographics
NPI:1932349966
Name:GREEN, KANDYCE LYNZE (RDH)
Entity Type:Individual
Prefix:
First Name:KANDYCE
Middle Name:LYNZE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2702
Mailing Address - Country:US
Mailing Address - Phone:708-425-1134
Mailing Address - Fax:
Practice Address - Street 1:2803 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2702
Practice Address - Country:US
Practice Address - Phone:708-425-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.012293124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist